HOOPER'S 

PHYSICIAN'S VADE MECUM: 



WITH AN OUTLINE OF GENEKAL PATHOLOGY, 
THERAPEUTICS, AND HYGIENE. 

EIGHTH EDITION. 

H 

REVISED 



WILLIAM AUGUSTUS GUY, M.B.Cantab, F.B.S., 

FELLOW OF THE EOYAL COLLEGE OF PHYSICIANS ; 

PROFESSOR OF FORENSIC MEDICINE, KING'S COLLEGE, LONDON ; 

PHYSICIAN TO KING'S COLLEGE HOSPITAL ; ETC. ETC. ; 

AND 

JOHN HARLEY, M.D. Lorn, F.L $., 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS ; 

HONORARY FELLOW OF KING'S COLLEGE, AND LATE ASSISTANT PHYSICIAN TO 

KLNG'S COLLEGE HOSPITAL; 

ASSISTANT PHYSICIAN TO THE LONDON FEYER HOSPITAL. 



LONDON: 

HENRY RENSHAW ; WHITTAKER & CO. ; SIMPKIN & CO. ; CHURCHILL & SONS 

HOULSTON & WRIGHT. 

EDINBURGH: A. & C. BLACK; MACLACHLAN & CO. 

DUBLIN : FANNIN & CO. 

' 18 6 9. 



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PRINTED BY WILLIAM CLOWES ASP SONS, STAMFORD STREET 
AND CHARING CROSS. 



EDITOBS' PEEFACE. 



The original work of Dr. Hooper, published in 1823, was so 
successful, and passed through so many editions, as to induce 
the proprietors to place it in the hands of successive Editors, 
by whom it was improved and enlarged. 

From his Preface, it appears that the object he contem- 
plated was to furnish a concise treatise on the practice of 
medicine for the use of Student and Practitioner. After his 
death an Introductory Part was added, containing a short out- 
line of Physiology, Pathology, and Therapeutics, some brief 
directions for Clinical Examination, and a sketch of Symp- 
tomatology and Semeiology. This, which did not occupy more 
than sixty-five pages, was entirely re -writ ten in the first 
edition entrusted to Dr. Guy, who is mainly responsible for 
the additions and alterations made in this part in all the sub- 
sequent editioris ; while Dr. Harley is now similarly responsible 
for the matter contained in the second jDart. Both parts have 
been largely illustrated by engravings. 

The general aim and scope of the work is fully explained 
in the Introduction. 

In making the extensive changes and additions above indi- 
cated, the original intentions of the Author, to make this work 
practically useful to the Student and Practitioner, have been 
strictly adhered to, and we believe it will now be found the 
most comprehensive work of the kind hitherto published in 
this country. 

Many original observations and practical remarks, embody- 
ing the results of Dr, Harley's experience, are contained in 
the text of the second part. Those contributed by Dr. Guy 
to former editions are distinguished by the initial G. 

WILLIAM A. GUY, 

26, Gordon Street. 

JOHN HAELEY, 

78, Upper Berkeley Street, 
Portman Square. 
Novemher, 1868. 



PART I. 

GENERAL PATHOLOGY AND THERAPEUTICS, 



CONTENTS. 

Chapter 
I. — Health and Disease. 

II. — Causes of Death. 

III. — Physiology and General Pathology. 

1. Of the Fluids.— 2. Of the Circulating System.— 3. Struc- 
tural Physiology and Pathology. — 4. Of the Nervous 
System.— 5. Of the Mind. 

IV. — Examination of the more Important Symptoms and 
Signs of Disease. 

1. Of the Urine. — 2. Of the Abdomen and Organs of Digestion. 
— 3. Of the Chest, and the Organs of Respiration and 
Circulation. — 4. Of the Pulse. — 5. Of the Respiration. 
— 6. Of other Symptoms and Signs of Disease. 

V. — Hygiene. 

1. Private Hygiene. — 2. Public H) T giene. — 3. Dietaries. — 
4. Deodorants, &c. 



VI. — General Therapeutics. 

1. Remedies applicable to Diseases of the Alimentary Canal. 
— 2. Remedies which modify the Composition of the 
Blood. — 3. Medicines which act on the Organs of Cir- 
culation. — 4. Remedies adapted to the Removal of the 
Solid Structures of the Body. — 5. Remedies which act 
on the Nervous Svstem. — 6. Nursing. 



INTRODUCTION. 



This book is intended to be, in the largest sense of the term, a practical 
work ; that is to say, it aims at bringing together, in a small compass, 
and in a form easy of reference, those items of information which the 
practitioner would wish to possess when he stands at the bedside, or 
when he studies a case with a view to its treatment. 

The first and most obvious requisite for a practitioner is to be able 
to recognise a disease when he sees it, to distinguish it from others that 
resemble it, and to foretell its probable course and termination. The 
treatment he adopts will be judicious in proportion to the certainty 
with wdiich he recognises, and the accuracy with which he discriminates, 
diseases ; and will be either rational or empirical, according as he does 
or does not understand their real nature and true cause. 

But a facility of recognising and discriminating diseases, a knowledge 
of their nature and causes, of their ordinary course and termination, 
and of their appropriate treatment, though essential to sound and suc- 
cessful practice, are not the only qualifications for it. Theie is a vast 
amount of information of a truly practical character, which does not 
find a place in formal descriptions of individual diseases, though com- 
prising all these particulars. Such descriptions must be regarded either 
as condensed histories of the more perfect forms of disease, or as abstracts 
of the leading features observed in the ordinary run of cases, with an 
occasional notice of the more remarkable exceptions to the rule ; but 
age, sex, and original and acquired peculiarity of constitution, give rise 
to differences in health, or habitual departures from it, which remark- 
ably affect the severity and even the character of diseases. Hence a 
knowledge of the mode and degree in which both health and disease are 
affected by difference of age and sex, and of constitution, whether origi- 
nal or acquired, is not less essential to safe and successful practice than 
is a special description of diseases themselves. 

The list of the necessary acquirements of the practical physician, how- 
ever, is not yet complete. It often happens that, at the bedside, great 
importance attaches to an individual symptom, and questions occur in 
relation to it, which are not, and cannot be, answered in the short space 
devoted to the description of the disease of which it forms a part. The 
symptom may be common to several diseases, or it may be a question 
whether, though assumed to be a symptom of disease, it be not com- 
patible with health. Moreover, theie are many symptoms or signs of 



INTRODUCTION. 

disease which are detected only by very close examination, and by the 
use of instruments or of chemical tests ; and in using these instruments 
and applying these tests, many precautions are necessary that are not 
easily borne in mind, and with regard to which the practitioner may 
often require to refresh his memorv. 

One other consideration suggests itself in this place. No man, what- 
ever his pursuit, deserves the name of a practical man whose knowledge 
and resources are limited by the experience of those who have gone 
before him. In all employments, and in none more than in the prac- 
tice of medicine, new events and rare combinations are continunllv 
presenting themselves, which can only be understood and successfully 
encountered by the aid of general principles. Hence the necessity for 
the physician of a knowledge of pathology and therapeutics, which 
supply the general principles that are to snide him in treating cases of 
disease, or complications of which he has no previous experience. 

A physician who is well versei in all these particulars may lay claim 
to the title of learned in its best sense : if he have made this knowledge 
his own by diligent observation at the bedside, and by the constant use 
of instruments and application of tests, by which alone the value of 
symptoms can be determined, he will have earned for himself the name 
of experience ; and if to learning and experience he unite the faculty of 
prompt and ready use of the knowledge he has acquired, he is truly a 
pra otica I phys ic io.n. 

A very wide and comprehensive meaning is here given to th^ terms 
leo -ning and experience, and to the phrase practical physician. Indeed, 
it is of the first importance that these words should not be used in a 
low and vulgar sense. It is too much the custom to call a man a prac- 
tical physician because he gives no time or attention to anything but 
the routine duties of his profession : and to deny him that title if he 
devote his leisure to what are called scientific pursuits, even though 
those pursuits should be in immediate connection with, and have a direct 
bearing upon, practice. A strong conviction that no man is truly prac- 
tical who is not al-o possessed of an extensive scientific knowledge of his 
profession, has presided over the prepnrat : on of this work, and has 
induced the Editors to extend it beyond the limits usually assigned to a 
so-called practical treatise. 

In order fully to carry out the practical views here indicated, this 
work is divided into two distinct parts, of which the first embraces, in 
a connected form, those more general considerations that make up the 
sciences of General Pathology and Therapeutics, while the second con- 
tains, in a form easy of reference, a description of diseases, their diagnosis 
and prognosis, their rationale, and their treatment, or what is usually 
known as the Theorv and Practice of Medicine. 

The First Part is divided into six chapters, under the following 
titles: — 1. Health and Disease, comprising such general observations 
upon either as seem to have the most practical bearing ; pointing out 
the way in which both are varied by age, sex, temperament, and mode 
«> r life, and concluding by an explanation of the terms in common use 
for distinguishing diseases from each other, and giving precision to our 



1KTE0DUCTI0N. 

views and statements concerning them. — 2. Causes of Death. In this 
chapter some of the leading facts that have been ascertained in reference 
to the causes of death are brought together with a view of giving to the 
student and practitioner some idea of the relative frequency and impor- 
tance of the diseases which prove fatal to human life. — 3. Outline of 
Physiology and General Pathology. — In this chapter those facts and 
theories which have the most direct bearing upon the practice of medi- 
cine are brought together, and briefly stated, all unnecessary discussion 
being carefully avoided, and the more important and minute details 
being reserved for — 4. Examination of some of the more important 
Symptoms and Signs of Disease, comprising the Urine, the Viscera of 
the Abdomen and of the Chest, the Pulse, and the Respiration. Chapter 5 
treats of Hygiene, private and public ; while Chapter 6 contains An 
Outline of General 'therapeutics, comprising such general principles as 
have been laid down for the preservation and improvement of health 
and the treatment of disease, together with an account of the principal 
remedies, and of their mode of operation. 

The Second Part, or the Practice of Medicine, properly so called, is 
also distributed into chapters as follows : — 1 . States of the System, as dis- 
tinguished from diseases properly so called. — 2. Local Diseases, affect- 
ing all or several of the organs or textures of the body. — 3. Febrile 
Diseases without essential local complication. — 4. Febrile Diseases with 
essential local complication. — 5. Febrile Diseases arising from local 
causes. — 6. General Disease (not febrile), with essential local complica- 
tions. 

The remainder of the diseases are distributed into ten chapters, as 
follows : — 1. Diseases of the Nervous System. — 2. Diseases of the Organs 
of Circulation. — 3. Diseases of the Organs of Respiration. — 4. Diseases 
of the Organs of Digestion and Abdominal Viscera. — 5. Diseases of the 
Urinary Organs. — 6. Diseases of the Organs of Generation. — 7. Diseases 
of the Organs of Sense. — 8. Diseases of the Skin and its Appendages. 
9. Parasitic Animals ; and 10. Poisons, followed by a list of antidotes to 
the principal poisons. 

The Second Part is brought to a close by an extensive collection of 
Formulas, preceded by classified lists of the preparations of the Phar- 
macopoeia, with their doses. 

Glossarial and general indices complete the volume. 



THE 



PHYSICIAN'S VADE MECUM. 



CHAPTEE I. 

HEALTH AND DISEASE. 



1. Health has been defined as the integrity of every structure, and 
the perfect, harmonious play of every function of the living body ; and 
some writers have indulged in long descriptions of it, more remarkable 
for elegance of diction than utility. Perfect health is as rare as 
extreme old age, and, like perfect beauty, is an ideal hard to describe, 
and compounded of the perfections of many different individuals. 

2. In strict propriety of language, perhaps there is but one condition 
of the body to which the term ' health ' can be applied, all others being 
deviations, more or less wide, from that condition ; but for practical 
purposes, it is well to understand that there may be departures from 
the standard of perfect health, to which, nevertheless, the terms disorder 
or disease would be inapplicable. 

3. That health is a condition admitting of degrees is shown by the 
familiar use of such terms as 'good,' 'perfect,' 'strong,' 'vigorous,' 
1 robust,' 'feeble,' ' delicate ' — differences generally recognised, not only 
as belonging to the same person at different times, and at different 
periods of life, but also as distinguishing one individual from another. 

4. But besides these differences in degree there are differences in 
kind, corresponding more or less closely to peculiarities of external 
form, and indicating a tendency to particular diseases, or to a peculiar 
character attaching to all the diseases to which the person may become 
subject. These differences have long been recognised as Tempera- 
ments — a word wanting in precision, but, like many others current 
among medical men, embodying a useful generalization. 

5. Four temperaments are generally recognised — the sanguine, the 
phlegmatic, the bilious, and the nervous. 

B 



- OX HEALTH AXD DISEASE. 

6. The sanguine temperament is characterised by moderate plump- 
ness of person and firmness of flesh. The hair is red or light chestnut, 
the eyes blue, the complexion fair and florid, the skin soft and thin, the 
circulation active, the pulse full and frequent, the countenance ani- 
mated, the movements quick, the passions excitable, the mind volatile 
and unsteady. 

7. The phlegmatic or lymphatic temperament is distinguished by 
roundness of form and softness of flesh. The hair is fair, the eyes light 
blue, gray, or hazel, the skin pale, the lips large, and the face wanting 
in character and expression. The circulation is languid, the pulse 
slow, and all the functions, bodily and mental, are torpid. 

8. The bilious temperament is recognised by firmness of flesh, harsh 
outlines of the person, and strongly-marked and expressive features. 
The hair and eyes are dark brown or black, and the complexion 
swarthy. The superficial veins are prominent, and the pulse is full, 
firm, and of moderate frequency. There is much energy of character, 
with great power of endurance physical and mental, and permanence of 
impressions. When the mind is unusually serious and sad, this is 
called the melancholic temperament. 

9. The nervous temperament is distinguished by a small spare form, 
with soft and slender muscles. The features are delicate, the hair fair, 
and the complexion pale or slightly tinged with red ; the lips thin, and 
the eyes light and sparkling. The pulse is small, frequent, and quick, 
and easily excited by emotion. The senses are acute, the thoughts and 
movements quick, and the imagination lively. 

10. Pure specimens of these temperaments are rare. In most persons 
two, or even more, are found combined, and these combinations are 
known as mixed temperaments. Thus we may have a nervous- 
lymphatic, or a sanguine-bilious temperament, the nervous element 
preponderating in the first, the sanguine element in the last. In some 
instances the leading characteristics of the two temperaments are so 
distinct, that we have no difficulty in recognising them ; but they may 
be so blended as to make it hard to say which predominates. We may 
also encounter in the purest specimens exceptions to the rule ; such as 
a pulse of 50 in a youth with all the outward marks of the sanguine 
temperament. 

11. Each of these temperaments predisposes to its own class of 
diseases, — the sanguine, to acute inflammation and active haemorrhage ; 
the phlegmatic, to congestions and subacute inflammations, to glandular 
and tubercular diseases; the bilious, to disorders of the digestive 
organs, with depression of spirits ; and the nervous, to undue mental 
excitement. 

12. Among the peculiarities of form and appearance which combine 
to constitute the temperaments, there are some that claim attention as 
indications of strength or weakness. Thus, coeteris paribus, the large 
chest is an indication of vigour; the small chest, of weakness ; the thin 



DIATHESIS — HEEEDITAEY PREDISPOSITION. 6 

lip, marked features, and small joints, of tone ; the full upper lip, rounded 
form and features, and large joints, of constitutional debility. 

13. There are other combinations again which prevail among persons 
subject to certain diseases or classes of disease, and these are known as 
Diatheses, For instance, a fair complexion, fine hair of different shades 
from light to dark chestnut, a blue or gray eye, and long eyelashes, 
with a thick upper lip, form a combination very frequent in scrofulous 
persons ; and the same combination, the thin upper lip being substi- 
tuted for the thick, is as common in consumptive patients. The one 
may be termed the strumous or scrofulous, the other the phthisical or 
consumptive diathesis. They are probably one and the same diathesis, 
slightly modified. 

14. The term diathesis is also used to designate the character of 
constitution of persons in whom the urine presents certain peculiarities. 
Hence the terms oxalic acid, lithic acid, and phosphatic diathesis, applied 
to persons whose urine yields oxalate of lime, lithic acid and its salts, 
and phosphoric acid and its salts, in excess, accompanied by other marks 
of impaired health. 

15. These peculiarities which, under the names of temperament and 
diathesis, distinguish one man from another, may be transmitted from 
parent to child, and are then said to be due to Hereditary Predis- 
position. 

1 6. This hereditary predisposition shows itself in the marked resem- 
blance of children to parents or ancestors. Sometimes the very tem- 
perament or diathesis of one or other parent is reproduced, coupled 
with a close resemblance of form and feature ; but, in most instances, 
the resemblance is limited to some strongly-marked feature, deformity, 
or peculiarity of taste, temper, or talent, which may even be trans- 
mitted through several generations. Such hereditary transmissions 
have been recognised in the royal families of Europe. In ancient Rome, 
the mild humanity of the Gracchi, the severity of the Catos, and the 
cruelty of the Claudian race ; in France, the factious rashness of the 
Guises, and the irritable and unbending character of the family of 
Mirabeau ; and in England, the vigorous intellect of our Gregorys, 
Herschels, and Pitts, furnish examples of the transmission of virtues, 
vices, and talents. Supernumerary toes and fingers, and certain defects 
in the organs of generation, may be cited as instances of hereditary 
deformity. 

17. Hereditary predispositions to disease are also of common occur- 
rence, and in extreme cases all or several children of a marriage become 
subject, at or about the same age, to a particular infirmity, such as 
blindness, or fall victims to some fatal disorder, such as pulmonary 
consumption. The diseases most frequently traced to this cause are 
scrofula, consumption, gout, epilepsy, insanity, cancer, and asthma ; 
and stone, gravel, and other urinary disorders, some cutaneous diseases, 
and haemorrhoids may be added to the list. On the other hand, a sound 



% OX HEALTH AND DISEASE. 

constitution, and a frame destined to last to a very advanced age, are 
blessings often handed down through several generations. 

18. Certain families, again, display a special liability to infectious 
maladies, such as typhus fever, scarlatina, whooping-cough, measles, and 
diphtheria, and an equally special mortality. As these acute and fatal 
seizures occur not in any one epidemic, or in one spot, but in different 
epidemics, at long intervals, and in places remote from each other, it is 
reasonable to attribute them to some common character in the persons 
attacked ; in other words, to family constitution. 

19. Hereditary diseases, as distinguished from hereditary tendencies 
to disease, are comparatively rare. Few children, for instance, are born 
with tubercles in the lungs, or with apoplexy. 

20. A peculiarity of form, character, or morbid tendency, has been 
"known to disappear in one generation, to appear again in the next. This 

form of hereditary predisposition has been termed Atavism. 

21. Hereditary diseases or predispositions to disease may be trans- 
mitted without any fault or imprudence on the part of parents. But 
children are often born into the world of infirm constitution and prone 
to disease, in consequence of circumstances referable to the marriage of 
the parents, such as extreme youth or advanced age, great disparity of 
age, or too close alliance in blood. 

22. The habitual state of health of the parents, or even their state 
of health at the time of conception, and that of the mother during 
pregnancy, may also determine the constitution of the offspring ; and 
there is reason to believe that the syphilitic taint in a parent is a cause 
of debility and a source of disease to his children. 

23. The facts just stated w T ith respect to hereditary predisposition 
are confirmed by observations on animals, which exhibit its effects not 
only in their outward form but also in their instincts and habits ; and 
Dr. Brown-^'equard has even found that guinea-pigs are subject to 
epileptic seizures similar to those which had been artificially induced in 
the parent animal by certain injuries to the nervous centres. 

24. Among the morbid states that have been by general consent 
traced to hereditary taint, the most important is scrofula. It consists 
in the deposit of a peculiar material in the glands of the neck, and of 
the mesentery ; in the substance of the lungs, liver, and kidneys ; in 
the membranes of the air-passages, intestines, brain, and spinal cord; 
which material may stir up inflammation and lead to important struc- 
tural changes, and so become the source of several lingering and wasting 
maladies. This morbid deposit appears to acknowledge as its principal 
cause a certain weakness and unsoundness of constitution, which, after 
giving rise to one disease in the parent, may show itself in his offspring 
in different forms. A man who has attained an advanced age after 
suffering all his life from epilepsy, may see his children afflicted — one 
with scrofulous enlargements and ulcers of the neck, a second with 



IDIOSYNCRASIES — SEX. 5 

tabes mesenterica, a third with pulmonary consumption, a fourth with 
white swellings of the joints and destruction of the bones of the spine, 
and a fifth with unsoundness of mind. 

25. An important practical inference may be drawn from what has 
been stated concerning temperaments, diatheses, and hereditary predis- 
positions — namely, that we shall encounter at the bedside a vast variety 
of constitutions, and many degrees of vigour, by which our treatment 
of disease must needs be influenced and modified. Hence it is an 
advantage to a patient that his physician should know his constitution ; 
but this advantage is often estimated too highly, and cannot compen- 
sate for a very moderate superiority in education, experience, or skill. 

26. Temperament, diathesis, and hereditary predisposition, then, 
constitute the most marked differences between man and man ; but 
there are others of more rare occurrence, and limited to comparatively 
few individuals, which are known as Idiosyncrasies. 

27. Of these there are three kinds. The first consists in an extreme 
susceptibility, or the reverse, to the action of certain medicines ; as 
when one person is salivated by a single small dose of a mild prepara- 
tion of mercury, while another will resist a long course of the same 
remedy in its strongest form. The second kind consists in the produc- 
tion of poisonous effects by the most common articles of diet ; as when 
fish, fruit, vegetables, and meat, usually accounted perfectly whole- 
some, occasion marked disorder of the digestive organs, accompanied 
sometimes with painful cutaneous eruptions. The third class consists 
in the inversion of the characteristic effects of medicines; as when 
opium acts as an aperient, and common Epsom salts as a narcotic. A 
class of mental idiosyncrasies might be added, consisting in strange 
preferences or aversions for objects usually deemed indifferent. 

28. The differences arising from temperament, diathesis, hereditary 
predisposition, and idiosyncrasy, may exist between males or females of 
the same age ; but other and very important differences depend upon 
sex and age. 

29. Sex. — The constitution of men differs from that of women; in 
disease as well as in health. In the constitution of the male there is 
more tone and strength, and in the structure of his body, more rigidity ; 
hence a greater proneness to inflammatory affections and active haemor- 
rhages ; females, on the other hand, have more sensibility and excita- 
bility, and a more lax and delicate fibre, with a strong tendency to 
nervous affections and to diseases of an asthenic character. The functions 
of menstruation, parturition, and lactation, also exercise a marked 
influence on the health of the female, especially in the production of 
disorders of the circulation and nervous system. 

30. The diseases of men, taken one with another, are more fatal than 
those of women ; men are also more exposed to accident and violence, 
and fall in greater numbers into habits of intemperance. Hence the 



b ON HEALTH AND DISEASE. 

lower rate of mortality of females, their greater longevity, and the 
excess of women among the living population. 

31. This difference in the rate of mortality of males and females 
obtains at every period of life except the interval from 15 to 35, when 
the deaths of females are in excess, and the intervals from 5 to 10 and 
35 to 45, when the numbers are equal ; and it even shows itself in 
infancv, when sex might be supposed to have least influence. Male 
children under 5 years of age die at the rate of 7o, but female children 
at the lower rate of only 6'6 in the thousand. 

32. The most important practical consideration connected with sex 
is, the greater liability of males to inflammatory and sthenic diseases, 
and of females to asthenic and nervous disorders ; so that, as a general 
rule, if a male and female are attacked by the same disease, the former 
will bear depletion and lowering remedies better than the latter. 

33. Age. — There are several important practical considerations con- 
nected with age. In infancy, we have to bear in mind the gradual, 
and often imperfect, establishment of the function of respiration, and 
the consequent necessity of external warmth; in early childhood the 
disturbance produced by teething ; and throughout infancy and child- 
hood, the liability to disorders of the stomach and bowels on the one 
hand, and of the brain on the other. Diarrhoea, infantile fever, ab- 
dominal consumption, intestinal worms, and scrofulous affections of the 
absorbent glands, result fiom the activity of the organs of digestion and 
assimilation ; white swellings and scrofulous diseases of bone, from the 
active growth of the organs of locomotion ; convulsions and hydro- 
cephalus, from the large development and vascular condition of the 
brain. Inflammation of the lungs, often connected w T ith their imperfect 
expansion, and the febrile exanthemata (partly traceable to the fact that 
the first exposure to their contagions must occur during these early 
periods of life, complete the list of the more frequent and fatal diseases 
of infancy and childhood. 

34. As childhood passes into youth, the disorders of the alimentary 
canal become less frequent and fatal, and react less severely on the 
nervous centres. Intestinal irritation ends less frequently in abdominal 
consumption and water on the brain ; and in lieu of the convulsions of 
infancy, we encounter the more curable involuntary movements of 
chorea. 

35. Puberty, which occurs in either sex about the age of 14, entails 
familiar changes, physical and mental ; and, on women, the peculiar 
function of menstruation. The advent of these changes is often post- 
poned for a few years, during which women are subject to disorders 
dependent on the imperfect establishment or complete suspension of 
the menses. Of these disorders anaemia is the most common; but 
chorea and epilepsy, melancholia, and instinctive mania attest its occa- 
sional influence on the nervous system. 

36. The disproportion between the head and abdomen and the rest 



DEATHS AT DIFFEKENT AGES. 7 

of the body lessens as age advances, and by the twenty-first year the 
frame assumes its due proportions. By the twenty-fifth year, or a 
little later, it attains its full growth. In this period of youth dis- 
orders of the alimentary canal and of the nervous system are rare, but 
febrile and inflammatory affections are common ; and scrofula, which 
had shown itself in the form of enlarged glands of the neck, white 
swellings of the joints, and abdominal consumption, now takes the 
shape of consumption of the lungs. 

37. From the twenty-fifth to about the forty-fifth year, the body 
remains nearly stationary, but with an increasing disposition to cor- 
pulency. Daring the first part of this period, febrile and inflammatory 
affections, and pulmonary consumption, are rife ; but towards the 
fiftieth year, congestion and slow degeneration of the tissues of impor- 
tant organs take the place of inflammation, and apoplexy is henceforth 
a common and rapidly-increasing cause of death. In women, the in- 
terval from forty to fifty, with the years preceding and following, is 
marked by the cessation of the menstrual discharge, and the strange 
nervous affections which often accompany the ' change of life/ 

38. From fifty to sixty years, the body begins to show signs of loss 
of power and sluggishness of function, the prelude to that slow decay 
of which the progress is indicated by diminished sensibility, impaired 
memory, muscular weakness, scanty secretions, calculous affections, 
osseous deposits, and organic visceral disease. 

39. From this enumeration of the diseases prevailing among persons 
at different ages, it will be inferred, that the risks to which they are 
exposed, as measured by their mortality, differ considerably ; to what 
extent the following statement will show : — The period most fatal to 
life is the first year, during which one-fourth of all the recorded 
deaths takes place. During the four succeeding years, also, the number 
of deaths is so considerable, that the 25 per cent, of the first year 
becomes for the first five years 42 per cent. By the completion of the 
fifteenth year, this proportion is increased to nearly one-half. During 
the forty years from 15 to 55, rather more than a fourth of all the 
deaths takes place, each decade contributing in nearly equal proportion 
to the aggregate result. At 55 years three-fourths of the population 
have succumbed. From 55 to 85, 23 deaths in the hundred, or nearly 
another fourth, takes place ; the ten years from 65 to 75 being the 
most fatal. Two per cent, of the entire mortality is accounted for by 
the deaths after 85 years of age. A small number of healthy and 
vigorous persons of either sex reach, or even surpass, the age of 100, 
and a still smaller number are believed to have attained or exceeded a 
century and a half. The following is a condensed view of the distribu- 
tion of the deaths according to age : — 

Under 1 year, 25 deaths in 100, or 1 in 4. 

,, 5 years, 42 „ „ „ more than 2 in 5. 

„ 15 „ 49 „ „ „ nearly 1 in 2. 

„ 55 ,, 75 ,, „ „ 3 m 4. 



8 ON HEALTH AXD DISEASE. 

Or, if the whole mortality is distributed into four equal parts, it will 
take place in unequal times, thus : — 

Under 1 year .... one-fourth. 

1 to 15 (14 years) . . . one-fourth. 

15 to 55 (40 years) . . one-fourth. 

55 and upwards . . . one-fourth, 

40. These figures show the deaths registered at the several ages ; but 
as the number living at each age differ greatly, they do not display 
the true risk to which persons of different ages are subject. This is 
shown in the following table, both for males and females. 

Out of 1000 males and 1000 females living in England at each age, 
the deaths placed opposite to those ages occur, one year with another, 
among the English population — 



Ages. 


Males. 


Females. 


Ages. 


Under 5 


74 


63 


35 to 45 


5 to 10 


9 


9 


45 „ 55 


10 „ 15 


7 


5 


55 ,, 65 
65 ,, 75 
75 „ 85 


5 „ 15 


7 


7 


15 ,, 25 


8 


9 


85 „ 95 



Males. 


Females 


13 


13 


19 


16 


32 


29 


68 


61 


150 


137 


303 


281 



25 „ 35 .10 11 I 95 and upwards 452 452 

41. The figures which represent the rate of mortality of females 
show a curious approach to regularity of increase in the five decades 
from 5 to 55, and in the six from 45 to the end of life ; the mortality 
in the first series being nearly as the numbers 7, 9, 11, 13, 15, while 
that in the last series is not very remote from the numbers 15, 30, 60, 
120, 240, 480. It may therefore be stated, as a rough approximation 
to the truth, that from the fifth to the fifty-fifth year the rate of mor- 
tality increases by about 2 in the 1000 every ten years ; and after the 
fifty-fifth year the rate of mortality doubles every ten years. This 
statement is a fair approximation to the truth in the case of females. 

42. It is important to understand that the same age does not always 
represent the same degree of growth, or perfection of function. This 
fact is well illustrated in the female by the variable time of occurrence 
of the changes indicated by the appearance or suppression of the men- 
strual discharge. The most usual age for its first appearance is the 
fifteenth year ; but that event may happen at any age from eight to 
twenty-five. In very rare instances it has occurred earlier than the 
eighth year, and even in the very first year of life. So ako with the 
period of suppression. It may happen at any age from thirty -five, or 
even earlier, to fifty-six, or later; and it may recur at very advanced 
periods of life. 

43. Another important consideration in regard to age relates to the 
fatality of the same diseases at different times of life. As age advances, 
the structure of the vital organs becomes impaired, and less easy of 
repair. The disease.^ of childhood, therefore, are more simple, and 



DEATHS AT DIEFEKENT AGES. \) 

more amenable to treatment than those of more advanced periods of 
life. 

44. This general principle is well illustrated by the special case of 
the mortality from fever at different ages. As in the majority of fatal 
cases, fever destroys life by setting up inflammation in some important 
organ of the body, as the lungs, the bowels, or the brain, the mortality 
may be expected to keep pace with, and to be a measure of, the liability 
of the vital organs to fall into a state of disease, and to increase as the 
restorative power diminishes. The calculations of Mr. Finlaison, 
founded on the experience of the London Fever Hospital, fully confirm 
this expectation. If we suppose 100,000 patients to be attacked with 
fever, at each of the ages specified in the table, the mortality will be 
that shown in the column of deaths : — 



Age. 


Deaths. 


5 to 16 . . . 


. 8,266 


15 „ 26 . . . 


. 11,494 


25 „ 36 . . . 


. 17,071 


35 „ 46 . . 


. 21,960 


45 „ 56 . . . 


. 30,493 


55 „ 66 . . . 


. 40,708 


66 and upwards . 


. 44,643 



The risk to life from fever is therefore more than twice as great at 30 
as at 10 ; nearly twice as great at 40 as at 20, and at 60 as at 40 ; it 
is nearly five times as great at 60 as at 10, and nearly four times as 
great above 65 as at 20. Like results have been obtained for the 
febrile exanthemata, which, like fever, first affect the whole body, but 
in their progress attack individual organs ; for dysentery, as it attacks 
our troops in unhealthy stations, or under unwholesome circumstances, 
abroad ; and for other fatal maladies. 

45. The liability to sickness, and its duration when it occurs, also 
increase with age. This is shown in the following tabular abstract, by 
Mr. Neison, of a large number of returns from English and Scotch 
Benefit Societies : 



Age. 


Percentage 

Sick during each 

Year. 


Sickness per Annum 

among those Sick, in 

Weeks. 


Mortality 

per Cent. 

among the Sick. 


11—15 


21*9 


4-1 


1-0 


21—25 


22-0 


3-8 


3-1 


31—35 


21-0 


4-4 


3'8 


41—45 


23-0 


5*9 


4-5 


51—55 


27*6 


8'5 


6*2 


61—65 


35-6 


15-2 


8-6 


71—75 


58-4 


32-3 


12-1 


81—85 


74-5 


37*8 


18-4 



10 OX HEALTH AND DISEASE. 

46. The differences due to temperament, diathesis, hereditary pre- 
disposition, sex, and age, are still further extended and exaggerated by 
Air and Climate, Place of Abode, Supplies of Food and Water, Occu- 
pation, Habits, and Mode of Life. 

47. The most powerful of these influences is the atmosphere, which 
both affects the entire surface of the body by variations in its tem- 
perature, pressure, moisture, and electric condition, and by its contact 
w r ith the skin, and internal surface of the lungs, produces the most 
important chemical changes in the blood, and, through it, in the system 
at large. Several subtle poisons, of which some are given oft' from 
inorganic matter, others generated by animal and vegetable decom- 
position, and others again by diseased living bodies, are also held sus- 
pended in the air, and, when concentrated, cause fatal accidents, or 
severe diseases ; but when diffused in smaller quantity, impair the 
health, and lower the tone of the system. Smoke, dust, and metallic par- 
ticles, resulting from chemical or mechanical operations, also impair the 
functions of the skiu and lungs, and lay the foundations of fatal maladies. 

48. The temperature, moisture, pressure, and electric condition of 
the air, modified and blended by situation, soil, and the physical con- 
formation of the surrounding country, constitute climate, of which the 
prolonged effect on the frame is seen in the form and features, as well 
as in the condition of the several functions of the body. Some of these 
states of atmosphere deserve a separate notice, as having a marked 
influence upon health. 

49. The temperature of the air is by far the most important ; for it 
has been well ascertained that in temperate climates sickness increases 
as the temperature rises, while the mortality is greatest when the 
thermometer falls to the lowest point; so that a hot summer is very 
sickly, and a cold winter very fatal to life. The less mortal sicknesses 
of summer are diarrhoea, cholera, dysentery, and febrile affections, 
among the young and middle-aged ; the more mortal maladies of 
winter are pneumonia and bronchitis among infants and aged persons. 
As a high temperature promotes putrefaction and decay, it is obviously 
favourable to diseases dependent on atmospheric impurity. Hence, in 
former times, when our towns were in a much worse state than they 
are now, sickness and mortality were both at their height in summer ; 
and one result of the improved sanitary state of our crowded popula- 
tion is to shift the maximum mortality from the summer to the winter 
months. 

50. The facts that have been ascertained respecting the influence of 
temperature on the occurrence of fatal maladies may be briefly stated 
thus: — If we divide the year, as is usual, into four equal quarters of 
three months each, we obtain, for England, the following results: — 

1. January, February, March . . 25 deaths per 1000. 
J. April, May, June .... 22 „ 
.';. July, August, September . . . 20 „ ,, 

4. October, November, December .21 „ , 






INFLUENCE OF TEMPEKATUKE ON DISEASE AND DEATH. 11 

51. It" the twelve months are so grouped as to correspond more 
closely with the four seasons of the year, the mortality, for London, is 
represented approximately by the following figures : — 

Winter (December, January, February) . . 16 deaths. 

Autumn (September, October, November) 15 ,, 

Summer (June, July, August) 14 „ 

Spring (March, April, May) 14 „ 

52. If a still better distribution is made, into the four hottest, four 
coldest, and four temperate months, we have, for London, the following 
proportions : — 

Four coldest months (Dec, Jan., Feb., March) 21 deaths. 
Four hottest months (June, July, Aug., Sept.) 19 ,, 
Four temperate months (April, May, Oct., Nov.) 18 ,, 

So that, in whatever way the months are grouped, the coldest are most 
fatal ; while, as appears from the last comparison, the hot months rank 
next in fatality, those of intermediate temperature being the least fatal. 

53. The fatal effect of a low temperature is strikingly shown by a 
comparison made by the Registrar-General between the deaths in ten 
consecutive cold days in November and December, 1856, and ten 
warmer days preceding and following them. The ten cold days had a 
mean daily temperature of 34°, and a mean nightly temperature of 27° ; 
and the ten warm days a mean daily temperature of 51°, and a mean 
nightly temperature of 47°. In the ten colder days there died of con- 
sumption 232, of bronchitis, pneumonia, and other diseases of the lungs 
502, of diseases of the heart 73, of diseases of the brain 170, and of 
other diseases 867. In the ten warmer days, the deaths by the same 
diseases, in the same order, were 163, 394, 51, 172, and 725. In con- 
sumption, bronchitis, and other diseases of the lungs, and in heart-disease, 
therefore, a fall of about 20 degrees of temperature caused the deaths to 
rise in the ratios of from 16 to 23, 39 to 50, and 51 to 73 ; while the 
total deaths in the colder are to the total deaths in the warmer days as 
18 to 15. 

54. The influence of temperature in promoting disease and undermin- 
ing health is most distinctly displayed in the inhabitants of temperate 
climates when living in countries strongly contrasted with their own. 

55. The temperatures of different parts of the world are also believed 
to contribute largely to the diseases of the native populations. The 
countries within the tropics, or bordering on them, are scourged by in- 
termittent and remittent fevers of the most intractable types, by yellow 
fever, by diarrhoea, dysentery, and cholera, and by diseases of the liver; 
while the countries verging on the North Pole are the homes of catar- 
rhal affections, influenza, diseases of the organs of respiration, and 
scurvy ; and the countries in the temperate zone, between the tropics 
and the poles, of fevers of the continued type, typhus and typhoid 
fevers, with intermittent and remittent fevers of a more tractable cha- 



12 OX HEALTH AXD DISEASE. 

racter, consumption, rheumatism, and cutaneous diseases of great variety, 
and often of great severity. 

58. The diseases proper to the several regions of the globe also pre- 
vail in countries which share with them a similar temperature; so that 
isothermal lines, or lines of equal temperature, are lines of disease also. 
Thus the diseases incident to countries in or near the tropics prevail 
along the equator of heat, or mean annual isothermal line of 82"4° Fahr. ; 
and in and near all that zone or region which is bounded north and south 
by the isothermal line of 68 D ; while the diseases of the temperate zone 
occur in the countries lying on or near the isothermal line of 50°; and 
those of the polar zone or region on or near the isothermal line of 41°. 
It may be useful to trace the course of these three isothermal lines, 
and to mention the countries or cities which they traverse or touch: 

(1.) The isothermal line of maximum temperature, or equator of 
heat (82*4° Fahr.% traverses, or passes near, the southern coast of the 
Gulf of Mexico, the Gulf of Guinea, the Straits of Bab-el-Mandel, and 
the fortress of Aden, the southern point of Hindostan and the city of 
Madras, and the islands of Sumatra and Java. 

(2.) The northern isothermal line of 68° traverses California, skirts 
the north coast of the Gulf of Mexico, touches the island of Madeira, 
the fortress of Gibraltar and the city of Algiers, runs along the south 
coast of the Mediterranean, and passes through China at the latitude of 
Nankin. The southern line traverses South America, from Potosi to 
Santa Fe, touches the Cape of Good Hope, and cuts off all that 
southern portion of Australia which has become the home of English 
colonists. 

(3.) The northern isothermal line of 50° touches New York and the 
southern point of Ireland, traverses the northern coast of the Black Sea, 
the Caspian, and the sea of Aral, and passes between the northern and 
southern islands of Japan. The southern line traverses the southern 
point of South America, runs north of the Falkland Islands and south 
of Van Diemen's Land, and cuts off the southern angle of New 
Zealand. 

(4.) The isothermal line of 41° touches Quebec, the south coast of 
Iceland, Stockholm, and Moscow, cuts in half the northern island of 
Japan, and runs south of the peninsula of Kamtschatka. 

57. This sketch of the chief points of the earth's surface touched by 
lines of equal temperature may serve to direct attention to the influence 
of heat in the production of disease. It must, however, be borne in 
mind that the diseases incident to the several zones may pass beyond 
the limits assigned to them, whenever, from local causes, the tempera- 
ture is raised or lowered, or when, the mean annual temperature being 
little changed, the summer is unusually hot or the winter unusually 
cold. In the one case, the diseases of the temperate zone may assume 
the character usually belonging to those of the tropics; in the other, 
they may approach more closely to those that prevail among nations 
nearer the pole. 



MOISTURE AXD PRESSURE OF THE AIR OZOXE. 13 

58. Nor should it be forgotten that the diseases prevailing in the 
several zones are not wholly due to temperature. Thus scurvy, which 
is very prevalent and fatal in the polar zone, may be traced in part to 
cold, and in part to the imperfect diet which the cold itself inflicts upon 
the inhabitants — a diet which would occasion scurvy in any part of the 
world. Again, the severe and fatal diseases of the tropical zone are not 
solely due to a high temperature, but to heat acting upon and develop- 
ing the miasma of damp and rank soils. Hence, troops and bodies of 
men, encamped on dry spots in the most unhealthy tropical districts, 
may escape, to a great extent, the prevailing maladies. It is by the 
discovery and occupation of such spots that the inhabitants of temperate 
climates can hope to maintain their possessions in countries having a 
much higher temperature than their own. 

59. The influence of moisture, as distinguished from that of the 
emanations which it promotes, is not so easy to trace as that of tempe- 
rature. There is reason, however, to believe that the inhabitants of 
damp soils and low-lying districts have less vigour than those of gravelly 
and sandy soils and the summits of hills and mountains. Experience 
also proves that many invalids suffer most when the air is loaded with 
moisture. 

60. It is also a notorious fact, that excessive humidity coexists with 
a high temperature in regions most fatal to human life ; as on the 
south coast of Africa, the Sunderbunds of Bengal, and the deltas of 
rivers, marshes, and jungles, in and near the tropics. In more tempe- 
rate regions the same combination of moisture with heat proves fatal to 
life during summer. 

61. Atmospheric pressure has also its effect upon health, and many 
invalids are susceptible even of slight changes in this respect. The 
oppression experienced in the divincr-bell, the diarrhoea incident to 
those who remove to residences in very lofty situations, and the 
hurried respiration, quickened circulation, and tendency to haemorrhage 
that accompany the ascent of high mountains, are illustrations of its 
more extreme effects. 

62. The influence on health of the electric condition of the air is 
shown by the uneasy sensations experienced by many persons before a 
thunderstorm. 

63. It has also been shown that the quantity of ozone (a modi- 
fication of oxygen caused by repeated electrical discharges, and charac- 
terised by a peculiar odour and increased power of oxidation) bears 
some relation to the prevalence of certain diseases, having been observed 
to be in defect during attacks of intermittent fever and of cholera, and 
in excess during at least one epidemic of influenza. 

64. But there are other atmospheric changes which are known to us 
only by their effects. Asiatic cholera, for instance, has, on four occa- 
sions, overstepped its usual limits, and spread over the greater part of 
the habitable globe ; and the entire class of infectious and contagious 



14 OX HEALTH AXD DISEASE. 

maladies exhibits variations in intensity from year to year which cannot 
be explained by differences of atmospheric temperature, moisture, and 
pressure, nor even by variations in the electric state of the air, and in 
the proportion of ozone. We are forced, therefore, to believe in the 
existence of certain obscure modifications in the state of the air, which 
are known as * Epidemic Constitutions.'' 

65. Although we cannot describe or explain these atmospheric con- 
ditions, we can form some idea of the extent of their influence by noting 
the annual fluctuations in the number of deaths due to infectious and 
contagious diseases. Thus, in the fifteen years from 1840 to 1854, the 
deaths from typhus and typhoid fever sank as low as 615, and rose as 
high as 1600; from erysipelas, as low as 113, and as high as 260; 
from whooping-cough, as low as 582, and as high as 1217 ; from measles, 
as low as 249, and as high as 1122 ; from scarlet fever, as low as 354 
and as high as 2132; from small-pox, as low as 87, and as high as 
890 ; and from influenza, as low as 35, and as high as 562. These 
are the deaths which took place in London in a million of inhabitants 
during the years and from the causes specified ; and it will be seen 
that while the deaths from fever, erysipelas, and whooping-cough fluc- 
tuated nearly as the numbers 1 and 2, those from measles varied as 
nearly 1 and 5, from scarlet-fever as 1 and 6, from small-pox as 1 and 
10; while the deaths fiom influenza were 16 times as numerous one 
year as another. Of these diseases small-pox is the only one directly 
influenced by legislation. The rest of the figures may be taken to 
prove the surpassing force of that condition of the a;r admitting neither 
of description nor measurement, and known to us only by its effects, for 
which we have at present no better name than ' Epidemic Constitu- 
tion/ 

6Q. These variations appear the more remarkable when they are con- 
trasted with the slight differences in the annual rate of mortality of many 
other diseases, especially those which depend primarily upon structural 
change. The deaths from pulmonary consumption, for instance, in the 
same years and among the same number of persons, fluctuated between 
the numbers 2645 and 3941 ; from inflammation of the lungs, between 
1340 and 21 09 ; from cancer, between 253 and 432; and from apo- 
plexy, between 426 and 607. 

A still more vivid idea is afforded of the extent of these fluctua- 
tions by the fact, that no combination of causes within or beyond 
human control — neither the weather, nor shipwrecks, nor the imports 
and exports of commodities, nor the prices of food, nor the quotations 
of the funds — are subject to such fluctuations from year to year. 

08. It is also worthy of remark that these peculiar states of atmo- 
sphere do not affect all diseases of an infectious or contagious nature in 
the same degree ; for the smallest number of deaths from small-pox, 
erysipelas, and measles, and the largest number of deaths from small- 
pox and influenza, occurred in years in which no other of the diseases 






ATMOSPHEEIC IMPURITIES IX TOWN AXD COUNTRY. 15 

ust mentioned attained their highest or lowest numbers ; while the 
least number of deaths from influenza coincided with the greatest 
number from measles ; and the least number from typhus fever with 
the greatest number from whooping-cough. On the other hand, the 
least mortality from scarlet fever and typhus coincided in the year 
1841, and the greatest from scarlet fever, typhus fever, and erysipelas, 
in 1848. But the epidemic visitations of cholera occurred in years 
marked by no peculiar excess or defect of any of these diseases.* 

69. Contamination of the air is a most efficient cause of impaired 
health, as well as a proline source of disease. In rural districts exha- 
lations fj-om stagnant pools and marshes, and from collections of 
manure, destroy the purity of the air ; while the atmosphere of large 
towns is subject to additional sources of pollution in the decomposition 
of animal and vegetable substances, the refuse of manufactories, the 
smoke resulting from the imperfect combustion of fuel, and the dust 
created by constant traffic. 

70. These impurities in the air of large towns, existing both within 
and without the dwellings of their inhabitants, tend to modify the' 
health of those reputed healthy, and to render them liable to diseases 
distinguished from those of rural districts by an absence of power or 
tone ; so that a disease which in the country would bear and might re- 
quire bloodletting, would, in large towns, scarcely admit of depletion, and 
might even demand an opposite mode -of treatment. This depressing 
effect of the atmosphere of large towns, displayed in the pallid aspect 
of those who are esteemed healthy, and in the want of power accom- 
panying their diseases, is a fact of great practical importance, always 
to be borne in mind at the bedside. 

71. A residence in large towns makes itself most felt in those of its 
inhabitants who work within doors, and who, in addition to the impure 
air of the town itself, inhale the close and heated atmosphere of shops 
and workshops, often in the absence of the wholesome stimulus of light. 
These persons exhibit, in an exaggerated form, the peculiar influence of 
a town life, and their diseases are marked in a still greater degree by 
want of power. So that there is as much difference between the in- 
door and outdoor labourers of large towns as between the inhabitants of 
town and country. A less marked difference is also to be observed 
between those who work within doors, with little and with more 
exertion . 

72. Town life, then, reduces the strength and vigour of the frame, 
and predisposes to diseases characterised by want of tone and power : 
and this effect is more marked in persons employed within doors and in 
those whose occupations demand least exertion. 

73. Many of the inhabitants of large towns who follow indoor 
employments, are exposed to another depressing and exhausting in- 

See Dr. Guy's two papers in "Statistical Journal," years 1855 and 1857. 



16 OX HEALTH AND DISEASE. 

fluence, namely, long hours of work or service, often extending far into 
the night, and sometimes usurping almost all the time that should be 
devoted to sleep. The London bakers during the whole of the year, 
compositors (and, it is to be feared, many of the most successful men 
in all trades and professions) during the session of Parliament, and 
milliners and dressmakers in the fashionable season, suffer greatly from 
this cause. 

74. The injurious influence of the causes just specified may be in- 
ferred from the excessive mortality of the inhabitants of large towns. 
Thus, while the annual mortality of rural districts in England and 
Wales varies from 18 to 22 in the thousand, that of town districts, not 
being seats of manufacture, will often amount to 25; and that of 
populous manufacturing towns and crowded sea- ports to 35, or even 
more. The mortality in some continental gapitals exceeds 40 in the 
thousand, and the very highest of these rates is exceeded in the worst 
districts of almost all our large towns. 

75. These figures present, it is true, an exaggerated view of the 
case, inasmuch as they are founded only on the number of deaths com- 
pared with the number of the living. When the ages of the living are 
taken into account, these differences are brought within much narrower 
limits. 

76. It must not, however, be supposed that the rural districts enjoy 
an immunity from the causes which impair the vigour and shorten the 
lives of the inhabitants of towns. Defective drainage and obstacles to 
the free movement of the external air often combine with overcrowding 
and neglect of cleanliness within doors, and a scanty and unwholesome 
diet, to counteract the beneficial influence of wholesome labour in the 
open air, and so impair the strength as to predispose to diseases of the 
low type prevalent in crowded city populations. Overwork, also, is 
not an evil limited to town populations. 

77. Many country places also share, with the least healthy portions 
of our large towns, the evil of a rich and ill-drained soil. Many a 
small village or isolated house in the country, like the old town of 
Liverpool, stands on a swamp, catching the water from higher ground ; 
and inviting a visit from every pestilence that happens to prevail. 

78. The diseases which cause the high mortality of town popula- 
tions are, in accordance with what has been just stated, the scrofulous 
affections of children, and the pulmonary consumption of the adult, 
together with febrile diseases and exanthemata characterised by an 
unusual tendency to the typhoid or adynamic form. The dust and 
smoke suspended in the air also give rise to diseases of the lungs, which 
exist in their most severe and fatal form among the scythe, knife, and 
needle grinders of Sheffield. 

79. Next to impure air and unwholesome residences, as causes of 
debility, comes scanty or unwholesome food. Insufficient nourishment 
is a chief cause of that want of power and tone which has been pointed 






TAINTED WATER — INTEMPERANCE. 17 

out as marking the inhabitants of large towns, and of some of our least 
favoured rural districts. In infancy and childhood, again, a diet not 
merely unequal to the wants of the frame, but unsuitable to the age, 
or destitute of some essential element of growth, often sows the seeds 
of future weakness and disease. At all ages, too, the poor either con- 
sume unwholesome food, or live on a diet wanting in the requisite 
variety of elements. Hence land scurvy and other allied diseases. 
Hence also, in earlier periods of our history, that scorbutic state of the 
mass of the population, which, co-operating with fevers, plague, and 
small-pox, gave rise to a destruction of human life of which happily we 
have now no experience. 

80. Water supplied in quantities insufficient for cleanliness, or of a 
quality unfit for drinking, is also among the recognised causes of im- 
paired health and actual disease. Water may also become the vehicle 
for the poison of lead, and, as recent experience has shown, of animal 
poisons thrown off from the body itself. Hence the part it bears in 
the propagation of fever and cholera. 

81. Another cause of weakness and disease is the abuse of spirituous 
liquors, to which the inhabitants of large towns are peculiarly addicted. 
Its effect on health is seen in the pallid and sodden aspect of the 
drunkard ; its influence on the character and course of disease in the 
fatal effects so often attending the slightest injuries in brewers' dray- 
men and other intemperate persons ; and its agency in shortening life 
by such facts as the following : — 

82. In men peculiarly exposed to the temptation of drinking, the 
mortality before thirty-five years of age is twice as great as in men 
following similar occupations, but less liable to fall into this fatal 
habit ; and the rate of mortality among persons addicted to intemper- 
ance is more than three times as great as in the population at large. 
At the earlier periods of life the disproportion is still greater, being rive 
times as great between 20 and 30, and four times as great between 30 
and 50. The annual destruction of life among persons of decidedly 
intemperate habits has been estimated at upwards of 3000 males and 
nearly 700 females, in a population of nearly 54,000 males and upwards 
of 11,000 females addicted to intemperance. Most of these deaths are 
due to delirium tremens and disease of the brain, or to dropsical affec- 
tions supervening on disease of the liver and kidneys. 

83. This extensive prevalence of intemperance among the English 
population should be borne in mind, especially as no fact is better 
established than the great danger of treating the diseases of intemperate 
persons by depletion or lowering remedies. The same remarks apply 
in a less degree to tobacco, chewed or smoked. The frequent union of 
drinking and smoking, and the fact, that, up to this time, no special 
structural disease has been traced to the excessive use of tobacco, 
obliges us to speak with some hesitation on this subject. But the fact 
that such good authorities as the late Sir Benjamin Brodie have strongly 

c 



18 ON HEALTH AND DISEASE. 

denounced this otherwise most objectionable habit, affords good reason 
for condemning it. 

84. Luxury, too, like intemperance, tends to undermine health and 
shorten life. Hence the higher orders are short-lived, and we may 
therefore safely infer, unhealthy while they live. Our agricultural 
labourers, in spite of their many disadvantages, live much longer ; and 
the aristocracy are nearly on a par with the members of benefit societies 
in Liverpool, the unhealthiest city in Eugland. Of the classes, too, 
which enjoy the most ample means of self-indulgence, those are most 
healthy who are least tempted. Thus the gentry are longer-lived than 
the aristocracy ; the aristocracy, than the members of royal houses ; 
and these last than crowned heads. Those who occupy the highest 
place in the social scale are probably, in point of health and longevity, 
but little raised above the very meanest of their subjects. In wealthy 
communities, persons who have no occupation of sufficient importance 
to interest and occupy the mind always abound. They constitute a 
large proportion of the class of habitual invalids, and those among 
them who have retired from a life of active exertion are believed to be 
the greatest sufferers. 

85. But while the unfortunate possession of wealth unpurchased by 
exertion tempts young men to sloth, luxury, and dissipation, and older 
men to less active self-indulgence, other classes are exposed to similar 
evils. The soldier, in time of peace, suffers from the ennui of insuffi- 
cient employment, is strongly tempted to indulge in dissipation, and is 
exposed, at the same time, to the evils of overcrowded and unwholesome 
barracks. Confinement, and the absence of employment calculated to 
interest and excite the mind, also undermine the health of prisoners 
and paupers. Recent inquiries have proved that the life of the soldier 
in time of peace is shortened by the causes now specified, and that the 
perfect sanitary arrangements of our prisons barely suffice to place 
their inmates on a level with the community at large; and it is highly 
probable that for every life which poor-laws save by averting starva- 
tion, a hundred are sacrificed by the imprisonment they inflict, and the 
contagious maladies which they promote. It is also probable that the 
self-imposed sloth of the wilfully destitute is as fatal as the involuntary 
privations of honest poverty. 

86. The enumeration of the causes of the wide differences existing 
between individuals reputed healthy, would be incomplete if no notice 
were taken of that strange and inexplicable change wrought in the 
body by contagious or infectious maladies, and especially by the febrile 
exanthemata, which confers a complete immunity from, or greatly 
diminished liability to, a second attack of those diseases. A similar 
result is brought about in one instance by a disease nearly allied to, but 
not identical with, the disorder from which the body is protected — by 
vaccination as a preventive of small-pox. 

87. Nor should we pass unnoticed a fact most important in its bear- 
ing, both on the treatment of disease, and the expectations we form of its 



DISEASE — STATES OF SYSTEM. 19 

success, namely, the existence of latent disease of the more important 
organs of the body. The lungs, heart, liver, or kidneys, which have 
seemed to perform their functions well, so long as they were not exposed 
to any unusual strain, may prove quite unequal to the strange work 
imposed upon them by the congestion which attends the cold stage ot 
febrile and inflammatory disorders, by the quickened circulation of the 
hot stage, or by the quick development of poisonous matters in such 
diseases as typhus and typhoid fever, scarlatina, or cholera. Let the 
function of the lungs be greatly hindered, or that of the kidneys wholly 
suspended, and the blood becomes charged with a poison which the frame, 
already diseased, is powerless to eliminate. 

88. The foregoing considerations respecting health, and the differ- 
ences that exist between one individual and another, may be thus 
summed up : — There are many original and many acquired differences 
between man and man. The original differences are those conveyed by 
the terms Temperament, Diathesis, Hereditary Predisposition, and 
Idiosyncracy ; to which we may add those dependent on Sex and Age. 
The acquired differences are due to Air and Climate, Place of Abode, 
supplies of Food and Water, Habits, Occupation, and Mode of Life ; and, 
in certain instances, to diseases previously undergone, and latent mala- 
dies unconsciously existing. 

89. When, therefore, we take into consideration the original differ- 
ences between man and man, and the various and complicated in- 
fluences to which the body is exposed in all states of society, but 
especially in highly-civilized communities, no additional argument will 
be necessary to establish the first great principle on which much of the 
practice of medicine hinges — that in health, and (by natural inference) 
in disease, every function of the body varies in different persons v:ithin 
wide limits of intensity. This fact is the key to the imperfection of 
Medicine as a Science and its difficulty as an Art. 

90. Disease. — To define disease we must first have defined health, 
for the one is but the negation of the other. In like manner, the de- 
scription and right understanding of disease depend upon the description 
and right understanding of health. Without attempting a formal de- 
finition, it will suffice to state, that disease is present when any structure 
of the body is changed (provided that change be not the direct and 
immediate effect of external injury), or when any function is either 
unnaturally active, or torpid, or altered in character. 

91. There is one important practical distinction which may be pro- 
perly insisted upon in this place : a distinction between disease, struct- 
ural or functional, and those unhealthy states of system brought about 
by the prolonged operation of the causes enumerated in § 69-87. Pre- 
vious to becoming the subject of any well-defined disease, the constitu- 
tion may have been brought, by the continued action of one or more of 
these causes, into a state which shall cause the disease itself to assume 
a more or less severe form, and even to depart in some respects from its 
usual character and course. Success in practice depends in no small 



20 ON HEALTH AND DISEASE. 

degree on the prompt recognition of these States of System, as well as 
of the several individual peculiarities pointed out in § 4-45. 

92. Diseases vary much (a) in their nature ; (6) in their form or 
type ; (c) in their duration and course ; (d) in their terminations ; and 
(e) in their mode of occurrence. Under these heads certain terms in 
common use will be explained. 

(a) Structural. — Consisting in alteration of structure. 

Functional. — Consisting in disordered function. 

Common. — Presenting the usual characters of common inflamma- 
tion, &c. 

Specific. — Peculiar, or departing from the common character. 

Malignant. — Structural diseases for which no remedy has yet been 
discovered, and which spread from texture to texture : as cancer. Also 
diseases which assume a very dangerous and intractable character : as 
malignant cholera, malignant typhus, malignant scarlet fever. 

Idiopathic. — Not dependent upon any other disease, 

Symptomatic. — Dependent upon, or being a symptom of, some other 
disease ; as dropsy following disease of the heart, liver, or kidneys. 

Primary. — The first in a succession of diseased conditions : for in- 
stance, a primary venereal sore. 

Secondary. — Following after or upon some other disease : as second- 
ary syphilis. 

93. (b) Continued. — Running their course without interruption in 
their symptoms. 

Intermittent or Periodical. — Interrupted by intervals of health. 
Remittent. — Having an alternate augmentation and diminution, but 
no complete cessation of symptoms. 

94. (c) Acute. — Of short duration and great severity. 
Chronic. — Of long duration and slight severity. 

These may be combined, as in ague, which is chronic in duration and 
acute in severity, or they may run into each other, the acute subsiding 
into the chronic, and the chronic being heightened into the acute. In 
one instance, the terms acute and chronic have been incorrectly used as 
mere marks of severity ; thus articular rheumatism is called acute 
rheumatism, or rheumatic fever, and rheumatism of the muscles chronic 
rheumatism. 

Sthenic. — Marked by vigour and excitement: nearly synonymous 
with acute. 

Asthenic. — Characterised by want of vigour, and nearly synonymous 
with typlioid and adynamic. 

95. (d) Most diseases terminate in complete recovery ; a considerable 
number in partial or incomplete recovery ; and one attack of illness in 
each person ends fatally. 

Recovery, even when complete, is generally gradual, but in certain 
cases the transition from disease to health is rapid and even sudden, 
The interval between the subsidence of the disease and the restoration 
of health is termed convalescence. If, during this period, the disease 



VAKIETIES OF DISEASE — NAMES OF DISEASES. 21 

returns, the patient is said to suffer a relapse ; and this is so common 
an occurrence in one form of continued fever that it has been called 
relapsing fever. 

The diseases from which the recovery is slow, are mostly those that 
exhaust the patient's strength by their severity or long duration ; such 
as fevers, acute inflammations, exhausting discharges, and paralytic 
affections. The diseases from which recovery is sudden or rapid are for 
the most part dependent on mechanical causes, such as calculi in the 
gall-duct or ureter. Neuralgic attacks also frequently pass off suddenly, 
to return with as little warning. 

Sometimes diseases terminate suddenly by profuse discharges, erup- 
tions, or external inflammations. Such events are termed critical, or 
they are called crises. Observation, both ancient and modern, seems 
also to have proved the existence of critical days, that is to say, days on 
which febrile disorders are prone to take a favourable turn. 

Diseases may also be said to terminate by metastasis, or transference 
from the part first attacked to some other, as from the joints to the 
stomach, heart, or brain, in gout ; or by extension to a texture similar 
to the one originally attacked, as when acute rheumatism having com- 
menced in the fibrous textures surrounding the large joints, seizes upon 
those in and about the heart. 

96. (e) Contagious and Infectious. — Both these terms are now used 
to designate diseases communicated from one person to another; the 
first by contact, the second without contact. 

Epidemic. — Attacking a number of persons at the same time, and 
recurring at irregular intervals ; as fever and small -pox. Some of these 
diseases, as cholera and influenza, spread from place to place with great 
rapidity, and attack at or about the same time the inhabitants of whole 
continents. 

Endemic. — Peculiar to certain localities, as ague, goitre, elephanti- 
asis, &c. The same disease may be both epidemic and endemic : thus, 
typhus fever, which is endemic in certain districts of large towns, be- 
comes epidemic in those districts in certain seasons or years ; cholera 
again is endemic in India and epidemic in Europe. 

Sporadic. — This term is applied to epidemic and endemic diseases 
when they attack one or two persons only, in which case they are said 
to occur sporadically. Such attacks are common at the beginning and 
end of epidemics. 

Zymotic. — This term, derived from a Greek word signifying ferment, 
is now applied to the entire class of epidemic, endemic, and contagious 
diseases. It is convenient as grouping together diseases allied to each other 
by similarity of cause, but objectionable as based upon a mere hypo- 
thesis obviously inapplicable to cases of sudden death due to the opera- 
tion of atmospheric and other poisons. 

97. Names of Diseases. (Medical nomenclature.) — No uniform plan 
has hitherto been pursued in giving names to diseases. The greater 
number have been named from some prominent symptom, as fever (from 
ferveo, to burn), hydrophobia, diabetes ; others from their seat and 



22 OX HEALTH AXD DISEASE. 

nature combined, as hydrocephalus, water on the brain ; or the seat is 
indicated by the root, and the nature of the disease by a common ter- 
mination. Thus the words pericardia's, pleura's, iritis, mean inflam- 
mation of the pericardium , of the pleura, of the iris. Words in com- 
mon use have also been superseded by terms descriptive of the nature 
of the disease ; as hyperemia (excess of blood), qualified by the words 
general, local, active, and passive, for plethora, inflammation, and con- 
gestion; and anaemia, similarly qualified, for chlorosis. 

98. Classification of Diseases. (Nosology.) — All the systems 
hitherto proposed have rested on some theory now disallowed ; and 
they have been attended with the usual inconvenience of all premature 
generalization — the inconvenience of associating dissimilar things, and 
separating such as are closely and naturally allied. For men engaged 
in learning, teaching, or practising medicine, that arrangement is best 
which classifies diseases according to their nature, when that is suf- 
ficiently ascertained, and in other cases according to the part of the 
body which they attack. But for state purposes that nosological 
system is to be preferred which places most prominently before the 
public, as a distinct class, the diseases admitting of prevention or miti- 
gation by sound sanitary measures. In this point of view, the classifi- 
cation adopted by the Registrar-General is deserving of commendation. 
A very complete classified list of diseases has also been recently put 
forth by the College of Physicians, The list comprises diseases, 
general and local ; poisons and injuries ; with an appendix of surgical 
operations, human parasites, and congenital malformations. 

99. There are some general considerations connected with disease 
of far higher importance than the use of terms, or the adoption of a 
correct nomenclature and scientific classification. These will be treated 
under the following heads : — (a) Causes ; (o) Symptoms and Signs ; 
(c) Diagnosis ; (d) Prognosis ; and (e) Treatment. 

100. {a) Causes of Disease. (Etiology.) — The causes of disease may 
be conveniently divided into proximate and remote. 

Proximate Causes (Causae abditae, continentes, occult causes.) — 
This term has arisen out of the twofold meaning of the word disease. 
When it is named from the part it attacks, and the nature of the 
change that part is undergoing, as pericarditis, or inflammation of the 
pericardium, the proximate cause is the disease itself; but if the name 
is the representative of a group of symptoms, as cough, dyspnoea, hectic 
fever, emaciation, &c. — the symptoms of pulmonary consumption — 
then the term proximate cause means the suppurating tubercle which 
gives rise to all these symptoms. If we are ignorant of the seat of a 
disease, as is the case with fever, the search after a proximate cause is 
but an inquiry into its real nature. 

Remote Causes. (Causae evidentes.) — All constant antecedents of 
an event are called causes of that event, and all constant consequences 
are called effects. Hence the same thing may have many causes. Thus 
an hereditary taint, intemperance, or want, and a common cold, may 



SYMPTOMS AND SIGNS OF DISEASE. 23 

unite in the same person as causes of pulmonary consumption. The 
hereditary taint may have rendered the person liable to the formation 
of tubercle, intemperance or want may have occasioned its actual de- 
position, and the cold may have excited it into activity. All these are 
causes of consumption, and the consumption may become the cause of 
death. How then are such causes to be distinguished from each other ? 
They are divided into predisposing and exciting. In this instance, the 
predisposing causes are the hereditary taint, and the mode of life : the 
exciting cause is the cold : and the proximate cause (if the term must 
be used) the suppurating lung. 

The condition of the body itself, however brought about, is the pre- 
disposing cause of any disease which may befall it : the exciting causes 
are, for the most part, external agents, such as cold and heat : these 
are also among the most powerful predisposing causes. Thus that 
combination which we call climate is the predisposing cause of a great 
variety of diseases ; and any one of the elements of which it consists 
may become an exciting cause. 

iSome of the principal predisposing causes of disease have been already 
considered (§ 4 — 87) when speaking of temperaments, diatheses, here- 
ditary predispositions, and idiosyncracies : of sex, age, occupation, and 
mode of life: of residence and climate. The local or constitutional 
injuries which supervene on severe attacks of illness must also be 
regarded as causes predisposing to fresh attacks of the same disease. 

The exciting causes of disease are chiefly mechanical and chemical 
injuries, unwholesome food, undue exertion of mind or body, sudden 
and violent atmospheric changes, parasitic animals and plants, atmo- 
spheric poisons, poisons generated by the human body itself, and those 
of venomous insects, reptiles, and mammalia. 

101. (6) Symptoms and Signs of Disease. (Symptomatology, semeio- 
tics.) — All lesions of structure, whether from external injury or from 
internal change, cause some disorder in the functions of the body, and 
almost every disorder of one function leads to derangement in those 
most closely connected with it. These disordered functions are called 
symptoms. Thus redness, swelling, heat, and pain are symptoms of 
inflammation ; and fever, which is itself recognised by a certain com- 
bination of symptoms, is a symptom of inflammation. 

102. The term symptom is variously qualified in medical writings. 
There are anamnestic symptoms, or those which relate to a patient's 
previous state of health; diagnostic, or those which distinguish his 
disease from others ; prognostic, or such as enable us to predict the 
event of his disease ; pathognomonic, or those peculiar to his malady, 
and to that alone ; therapeutic, or such as indicate the proper treat- 
ment ; objective, or such as can be seen, or otherwise perceived, by the 
physician himself; subjective, or such as consist in sensations of the 
patient. 

103. But we have also signs of disease ; and the word sign has not 
the same meaning as the word symptom, though the two are some- 



24 OX HEALTH AND DISEASE. 

times used without much discrimination. The difference is best shown 
by an example. Cough, expectoration, dyspnoea, hectic fever, night- 
sweats, and emaciation are symptoms of pulmonary consumption, but 
they are not signs, for they may all occur in other diseases ; but 
cavernous respiration and pectoriloquy are signs. So also expectoration 
is not a sign of consumption but a symptom, for it occurs in other 
diseases of the lungs ; but a certain kind of sputa is stated to be a sign 
of that disease. Signs, therefore, are pathognomonic or diagnostic 
symptoms ; and there is nearly the same difference between a symptom 
and a sign as between a character and a characteristic. Redness, pain, 
heat, and swelling are symptoms, characters, or phenomena of inflam- 
mation ; but redness and heat are at the same time symptoms and signs, 
characters and characteristics : pain and swelling are merely symptoms. 

104. The term physical sign is in common use among medical men ; 
it means a sign which is an object of sense. Thus, heat, redness, and 
swelling are physical signs of inflammation ; pectoriloquy of phthisis ; 
coaguiable urine of disease of the kidney. A physical sign is, there- 
fore, synonymous with an objective symptom. 

105. Symptoms are converted into signs by careful examination. 
If, for instance, a patient complain of pain in the chest, we proceed to 
ascertain whether it is external or internal, and if internal, what is its 
precise seat. If, again, a patient void urine different from that of 
health, we submit it to chemical tests, or examine it by the micro- 
scope, that we may find out the exact nature of the change it has 
undergone, and trace that change to its source. In this way we learn 
what the disease is, what its severity, what the proper treatment, 
what the hope of recovery. The more important methods of examina- 
tion, and especially those which require the use of instruments or tests, 
are described in chapter iv. 

106. The symptoms of disease are of very variable intensity ; and 
even the most characteristic are sometimes wanting, or replaced by 
their opposites. Thus, a frequent pulse is a most constant symptom of 
pulmonaiy consumption ; but in some cases it does not exceed its 
average in health ; while in others it falls below it ; and of two attacks 
of consumption occurring in the same person one has been known to 
be marked by a frequent, the other by an infrequent, pulse. This 
same symptom of increased frequency of pulse is among the most 
constant and characteristic attendants on fever, and yet some epidemics 
have been distinguished by a pulse below the standard of health. 

107. (c) Diagnosis, or the discrimination of diseases, is the neces- 
sary prelude to their treatment, it presupposes a correct observation 
and just appreciation of symptoms, and may be said to be the art of 
converting symptoms into signs. 

108. The first impression a patient makes on his physician is always 
an important element in the diagnosis. In most cases it enables him 
to form some idea of his previous habits of life ; to determine whether 



DIAGNOSIS AND PROGNOSIS. 25 

he is suffering from a slight or a severe illness ; and, in many instances, 
to decide at once upon the nature of his complaint. Thus, anaemia, 
consumption, pneumonia, emphysema, Bright's disease, fever, and 
severe disease of the heart, are often strongly marked on the very 
countenance of the patient ; and many other diseases, such as palsy 
and chorea, gout and rheumatic fever, tetanus and hydrophobia, several 
of the exanthemata, and skin diseases in general, betray themselves by 
single strongly-marked symptoms. The diagnosis in such cases is very 
easy ; but the task of the physician is much more difficult when the 
disease is either imperfectly developed, as in the first stage of eruptive 
fevers, and in incipient phthisis, or when the only obvious symptom is 
one which, like dropsy, may depend on several causes ; and it is still 
more difficult when the nature of the complaint must be inferred chiefly 
from the patient's description of his own sensations, or from a mere per- 
ception of the size and shape of a part of which the structure is concealed 
from view, as happens with the greater number of tumours, both 
external and internal. These are the cases which put the knowledge 
and skill of the physician to the test, and sometimes baffle both. 

109. In some cases we have to wait till the characteristic symptoms 
show themselves ; in others, to make minute stethoscopic examinations ; 
in others, to test the urine, or to use the microscope ; and in a few, to 
confess our ignorance. The effects of remedies, such as bloodletting 
and stimulants, also, in rare instances, serve as means of diagnosis. The 
symptoms which render us most assistance in distinguishing one disease 
from another will be carefully examined in a future chapter. 

110. (d) Prognosis. This word means foreknowledge, and, as used 
by the physician, the anticipation of the course and event of diseases. 
The power of foretelling the progress and termination of a malady is of 
the first importance, both as regards the treatment to be adopted, the 
well-being of the patient, his own satisfaction and that of his friends, 
and the reputation of the physician himself. A correct prognosis im- 
plies a just diagnosis, an accurate knowledge of the natural course and 
progress of disease, an appreciation of all the peculiarities, original and 
acquired, which distinguish one man from another (J 4 — 87j, and expe- 
rience of the virtues and power of remedies. 

111. Among the questions which the physician may be called upon 
to solve one of the most common is, whether the disease admits of cure ? 
The answer is sometimes very easy. A case of hydrophobia or of 
hysteria would present no difficulty. The one is as certainly fatal as 
the other is curable. But in a case of tetanus, of pneumonia, or of 
pulmonary consumption, the prognosis is more difficult. The first 
would be most probably fatal ; the second is always attended with 
danger, the amount of which will chiefly depend on the sex, age, tem- 
perament, and previous habits of the patient; the third is fatal in a 
large majority of cases, and the probability of ultimate and complete 
recovery is very slight. 

112. This latter disease — pulmonary consumption— affords a good 



26 OX HEALTH AND DISEASE. 

example of the necessity of caution in forming and stating our prog- 
nosis. The disease is incurable, and medicine, at best, only palliative ; 
but if, in every case, a physician were to foretell a fatal result, his 
reputation would suffer severely, for the simple reason that consump- 
tion, though ultimately fatal in nine hundred and ninety-nine cases out 
cf a thousand, is not necessarily fatal in any given attack, recoveries 
from several successive attacks being by no means unusual ; and this 
happens, not because the disease is curable, but because its fatality 
depends on the amount of tubercular deposit, and the issue of any par- 
ticular attack on the extent and activity of the suppurating process 
relatively to the power of the patient to bear the wear and tear con- 
sequent upon it. This is the true explanation of the asserted efficacy of 
medicines, regulated temperature, and change of climate in this disease, 
and of the reputed success of those irregular practitioners who select it 
as the object of their attention partly for the reasons assigned, and partly 
on account of the great number of people subject to its attacks. 

113. This is the place to speak of that vis medicatrix natures — that 
power inherent in the human frame to right itself when suffering under 
severe disorders — which our predecessors were wont to acknowledge 
with such befitting modesty as their invaluable coadjutor in the treat- 
ment of disease. We who withhold from nature the tribute that is 
her due, are as unwise as we are unjust ; for it is the obvious in- 
terest of the regular practitioner to extol the powers of nature, and 
to attribute to them a large share of the success so commonly ascribed 
to his own treatment. It is only in this way that the public can be 
rescued from the grasp of empiricism. The homceopathist (slave of an 
hypothesis invented by a heated enthusiast, and mainly supported by 
imaginary sensations developed by experiments on his own person ) 
attributes to infinitesimal doses virtues simply ridiculous, and results 
utterly impossible : but the regular practitioner can explain the cures 

to have been thus effected by that very vis medicatrix which so 

constantly Btands him in stead in his own treatment of disease, and to 

which he so rightly attributes so much of his own success. It is this 

which, counteracted by active medicines, but restored to 

: by non-interference, constitutes the really efficient agent of a 

• packs whose treatment, if honestly carried out in accordance 
with their own principles, would he perfectly harmless if it did not 
shut out prompt and active treatment in those eases which demand it. 
There are other quack medicines besides those given by the homoeopath, 
which, though far from harmless when carelessly administered, prove of 

rice in certain instances. The public fa informed of these suc- 
: not of the unsuccessful or the fatal ones. The frequent 

in pulmonary consumption, either without treatment, or 
under the use of remedies which could not have exercised any influence on 
tie- disease, ;_-<>«> far to complete the explanation of the success of quackery 

forma and guises; while the alleged efficacy of change 

of climate in I - an apt illustration of the occasional 

identity of the mistakes made by the regular and irregular practitioner. 



THE VIS MEDICATRIX TREATMENT. Zt 

114. These observations on the vis medicatrix receive support from 
the history of some of the greatest improvements in the art of healing. 
Three centuries ago, for instance, surgeons thought that they ought to 
treat gun-shot wounds with boiling oil. But Ambrose Pare, through 
the happy accident of his supply of boiling oil foiling short, was led to 
adopt that better treatment which consists in virtually leaving the 
sufferer in the hands of nature. At the same time, a contemporary of 
that great surgeon was boasting of his success in treating these wounds 
by a slimy mixture called the ' oil of whelps/ which had, in reality, the 
same happy effect of leaving nature to work her own cure in her own way. 

115. It follows, then, that to determine whether a patient's recovery 
has happened through the treatment adopted, or independent of it, or 
in spite of it, is often a task of extreme difficulty. The best physician 
may often decide amiss ; the ignorant empiric and equally ignorant 
public are utterly unqualified to fonn an opinion. 

116. (<?) Treatment. — A correct diagnosis, a knowledge of the nature 
of the disease itself, of the constitution of the sufferer, and of the 
virtues of remedies, are essential preliminaries to judicious treatment. 
The object to be aimed at will vary with each case. In one, it will 
suffice to remove the ascertained cause ; in another, it will be necessary 
to restore the healthy function or repair the diseased structure ; in a 
third, to palliate the suffering which the disease occasions. 

117. Our treatment is sometimes founded on a correct knowledge 
of the nature of the disease and the mode of operation of our remedies, 
in which case it is said to be rational; in other instances, we act in 
ignorance of both, and then it is said to be empirical. Again, it may 
be curative, or such as to restore the patient to perfect health ; palliative, 
or adapted to the alleviation of suffering ; preventive, or calculated to 
obviate the recurrence of disease, by maintaining habitually a better 
state of health. 

118. The abstraction of blood in inflammation is an example of 
rational treatment, for we know both the condition of the part affected 
and the modus operandi of the remedy. The use of quinine or arsenic 
in ague is merely empirical, for we understand neither the nature of 
ague nor the mode in which these medicines affect the body in curing 
it. The treatment of pulmonary consumption is necessarily palliative^ 
for, from the very nature of the complaint, it is obvious that it does 
not admit of cure. Such also is the case with many neuralgic affections, 
and with all malignant diseases. 

119. In the treatment of many diseases we combine the rational with 
the empirical, the curative with the palliative. Thus, during an attack 
of remittent fever, we might abstract blood to subdue local inflamma- 
tion, use cold-sponging to diminish the heat of the surface, stimulants 
to counteract debility, and quinine to effect a cure. 

120. Though the employment of remedies, the modus operandi of 
which we do not understand, is empirical, the act of generalisation by 



28 OX HEALTH AXD DISEASE. 

which we infer the utility of the same remedies in analogous disorders, 
lends to our empiricism something of a rational character. For example ; 
though the employment of quinine and arsenic in ague was originally 
pure empiricism, the use of those remedies, in the whole class of inter- 
mittent disorders, as a consequence of analogical reasoning, is entitled to 
a more complimentary epithet. 

121. In treating disease we are necessarily guided by the existing 
state of the patient. If, for instance, the skin, gums, and tongue are 
pale, we prescribe some preparation of iron ; if, on the contrary, they 
are florid, we shall probably order depleting or lowering remedies. Now 
these opposite states are said to afford indications of treatment — grounds 
or reasons, that is to say, for giving preparations of iron in the one 
case, and resorting to lowering measures in the other. On the other 
hand, these same states of system constitute grounds for avoiding the 
opposite modes of treatment ; in other words, they are contraindications 
of depletion and tonic treatment respectively. In like manner acute 
inflammatory symptoms, occurring in robust persons, indicate lowering 
remedies, and contraindicate stimulants. 

122. The considerations brought forward in this chapter will serve 
to show the extreme difficulty which attends the practice of medicine, 
and the necessity imposed on the physician of supplying himself with 
very extensive and precise information on all the subjects which can 
conduce to a knowledge of the human body, on the one hand, or of the 
virtues of remedies, on the other. But, after all that can be done, the 
science of medicine must remain extremely imperfect, and the art of 
healing very difficult. Our general principles, derived originally from 
particulars made up of many variable elements, must be reapplied in 
practice to individual instances as complicated as those out of which 
they were originally formed, so that precision is, in the nature of things, 
impossible, and certainty of very rare attainment. 

123. Other considerations, which go far to explain the acknowledged 
difficulty of medicine, both as a subject of scientific inquiry and of 
practical application, are : — the variable severity of diseases bearing the 
same name, the changes that occur in the progress both of acute and 
chronic cases, and the unequal strength of our remedies. When we 
reflect that, prior to the setting in of any given disease, the constitution 
of the patient, originally marked by peculiarities traceable to hereditary 
predisposition, has been subsequently modified by the powerful influ- 
ences already examined ; that the disease itself may vary within wide 
limits of intensity; that it passes naturally through many different 
phases ; that it may fall under observation and treatment at any part 
of its course ; that the remedies prescribed, being of variable strength, 
may be administered with more or less care and regularity, and the 
patient be tended with greater or less watchfulness and skill: — when 
we take all these circumstances into consideration, we cannot be sur- 
prised that medicine should be the most imperfect and uncertain of 
sciences, a conjectural and most difficult art. 






29 
CHAPTER II. 

CAUSES OF DEATH. 

124. Though the causes of death interest chiefly those medical men 
who are engaged in preventing disease, the practical physician profits 
by the study of them, inasmuch as he learns the relative frequency of 
the more severe diseases, and the demands they severally make on his 
attention. 

125. The causes of death form three leading groups; of which the 
first comprises mechanical injuries, scalds, burns, and corrosions, the 
several forms of suffocation, cold, want, intemperance, and poison ; the 
second, debility in infancy and decay in age; and the third, disease pro- 
perly so called. In England the deaths are distributed through these 
three classes in the following proportions : — 

Class I., 4 deaths; Class II., 16 deaths; Class III., 80 deaths. 

126. In Class I. about half the deaths are caused by mechanical 
injuries ; about a fourth by the several forms of suffocation (hanging, 
drowning, &c.) ; less than a fifth by burns and scalds; one per cent, by 
cold and want ; three per cent, by poison ; and three per cent by in- 
temperance (exclusive of delirium tremens and other fatal diseases 
occasioned by excess). 

127. In Class II. the deaths are divided between those that occur in 
early infancy from incomplete development and inadequate nutrition, 
and deaths from old age ; the excess being somewhat on the side of the 
first division. 

128. The 80 deaths in the 100 that remain after subtracting 
Classes I. and II., may be distributed into a few leading groups of disease. 
A very large and important group consists of epidemic diseases pro- 
pagated by contagion or infection, which destroy life by giving rise to 
severe local affections or by exhausting the vital powers. This comprises 
small -pox, sea rlet fever, measles, whooping-cough, typhus and puerperal 
fevers, and erysipelas. A second class of epidemic maladies is due, like the 
foregoing, to external causes, but not to contagion, or, if to contagion, not 
exclusively. To this belong ague, remittent and typhoid fevers, in- 
fluenza, diarrhoea, dysentery and cholera, diphtheria, quinsey, and car- 
buncle. A third class consists of diseases that prove fatal chiefly to 
infants and young children. They have their source in the local irrita- 
tion of teething, worms, or constipation, and lead to fatal affections of 
the brain and of the intestinal canal. This comprises infantile fever, 
marasmus, and hydrocephalus. A fourth — the largest class of all — is 
made up of diseases which consist in a structural change or degeneracy 



30 CAUSES OF DEATH. 

of some texture or organ. To this belong scrofula, pulmonary con- 
sumption, and cancer. Diseases occasioned by some special impurity, 
or change of consistence, in the blood, constitute another class, of which 
rheumatic fever, scurvy, and gout, with pyaemia, are members. The 
remainder of the list is made up of fatal diseases of special organs, and 
of the accidents attendant on childbirth. Of special organs, those ot 
respiration (even after exclusion of pulmonary consumption) occasion 
the highest mortality ; then, in order, those of the brain and nervous 
system ; organs of digestion ; heart and circulation. 

129. The 80 deaths from disease remaining after subtracting from 
the whole 100 deaths those due to all other causes, are made up in the 
following manner : — 

Diseases due to Structural Degeneration (including 

Pulmonary Consumption) 16 

Diseases of the Organs of Respiration (exclusive of 

Pulmonary Consumption) 15 

Contagious and Infectious Diseases 14 

Diseases of infancy and Childhood 9 

Diseases of the Brain and Nervous System .... 7 

Epidemic Diseases not being Contagious .... 6 

Diseases of the Organs of Digestion and Assimilation . 6 

Diseases of the Organs of Circulation 4 

Diseases due to changes in the Blood ..... 1 

Diseases of the Urinary Organs 1 

Childbirth, &c 1 

130. If we distribute fatal diseases, as far as possible, in accordance 
with the parts which they attack, we obtain, for 1000 deaths, the fol- 
lowing results : — 

Organs of Respiration 320 

Brain and Nervous System 144 

Organs of Digestion and Assimilation 104 

Heart and Organs of Circulation 35 

Urinary Organs lU 

Childbirth and Organs of Generation in the Female . 10 

Joints and Organs of Locomotion 9 

Skin and Integumentary System 6-638 

All other causes 362 

Total . . . 1000 

131. If from diseases of organs and systems of organs we pass to 
single diseases, we obtain for 1000 deaths, the following figures: — 

Pulmonary Consumption 125 

Bronchitis and Asthma 78 

Pneumonia 62 

Convulsions 59 

Scarlatina .... ........ 41 






ASTHENIA. 31 

Typhus and Typhoid Fever 38 

Diarrhcea, Dysentery, and Cholera 36 

Whooping-Cough 24 

Paralysis and Apoplexy, each 21 

Hydrocephalus and Measles, each 18 

Cancer 14 

Tabes Mesenterica 11 

Croup and Teething, each 10 

Influenza, Inflammation of Brain, and Bowels, each . 8 

Scrofula 7 

Small- Pox . , 6 

Erysipelas, Epilepsy, and Rheumatism, each ... 5 

Ileus, Intussusception, and Intestinal Stricture ... 4 
Inflammation of the Liver, Peritoneum, and Larynx, 

Jaundice, Ileus, Pleurisy, and Thrush, each ... 3 
Syphilis, Ulcer of Intestines, Hernia, Ascites, Inflam- 
mation of Stomach, and Blight's disease, each . . 2 
Pericarditis, Remittent Fever, Delirium Tremens, In- 
sanity, Diabetes, and Infantile Fever, each ... 1 
Quinsey, Purpura, Aneurism, Cyanosis, Gout, Intempe- 
rance, Inflammation of the Bladder, Carbuncle, In- 
flammation of the Kidney, Stone, Stricture of the 
Urethra, Ovarian Dropsy, Noma, Tetanus, Ague, 
Ischuria, Fistula, and Chorea, each less than ... 1 

The mortality from some of the last-named diseases is very small : — 
164 in the million from chorea; and 33 from hydrophobia. 

132. A chapter on the Causes of Death would be incomplete if some 
notice were not taken of what are sometimes called the proximate 
causes of death, or ' modes of dying.' 

Death may be said to happen when the heart ceases to beat. Hence, 
in considering the proximate causes of death, we are inquiring by what 
means the pulsation of the heart may be made to stop. The first and 
most direct mode is by an action on the structure of the heart itself, 
which may be either paralysed by a nervous shock, or weakened by 
chronic structural disease. The second, by withdrawing, suddenly or 
slowly, the blood which should act as its stimulus to contraction. The 
third, by cutting off, more or less suddenly, the arterial blood from the 
left side of the heart by an impediment to the breathing. These three 
causes of death, or modes of dying, may be fitly termed asthenia, syn- 
cope, and apnwa. 

133. (1.) Death by asthenia. The heart of a perfectly healthy 
person may be suddenly stopped by causes acting with great force on 
the nervous system: by the lightning-stroke, by strong mental 
emotion, by a stunning blow on the head, by a blow on the pit of the 
stomach, or by the shock of cold drinks. One or two active poisons, 
such as prussic and oxalic acid in full doses, certain poisons intro- 
duced directly into the circulation, air penetrating through an open 



32 CAUSES OF DEATH. 

vein to the right side of the heart, and the sudden effusion of even a 
small quantity of blood on the surface, or into the substance of, the 
brain may also cause this sudden arrest of the heart's action. The 
chronic structural diseases that bring about this sudden or speedy 
death are fatty degeneration, which impairs the muscular tissue itself, 
or ossification of the arteries, which checks the supply of arterial blood 
to the walls of the heart. Either of these conditions may so weaken 
the heart, that the causes just enumerated, acting with comparatively 
slight force, may bring about a sudden and fatal pause in its action. 

134. (2.) Death by Syncope. — This may be brought about either 
by the sudden pouring out of a large quantity of blood from a wounded 
or ruptured vessel, or by the slow drain of chronic haemorrhage or 
exhausting discharges ; the quantity of blood being so reduced, and its 
quality so impaired, that it ceases to act as an efficient stimulus to the 
heart. Ruptures and wounds of the heart destroy life partly by 
syncope and partly by impairing the propulsive power of the organ. 

135. (3.) Death by Apncea. — This is by far the most common 
form of death. The majority of persons die suffocated: a few by 
direct suffocation; a much larger number by that slow failure of 
respiration which attends the exhaustion of the strength by all severe 
diseases. Direct suffocation may be occasioned by constriction of the 
throat, as in hanging, strangulation, and throttling; by closing the 
mouth and nostrils ; by pressure on the chest ; by exclusion of air, as 
in drowning ; by the substitution of a gas not containing oxygen for 
atmospheric air ; by spasm of the glottis ; by inflammation and swell- 
ing of the upper part of the larynx, caused either by hot water or corro- 
sive poisons, or by disease ; and by small foreign bodies wedged between 
the walls of the rima glottidis. Direct suffocation is of comparatively 
rare occurrence in disease. It may arise from causes affecting the 
larynx, or trachea, as laryngitis and croup, or from collections of 
blood, pus, or mucus filling up the small branches of the air-tubes 
and the air-cells. It may also arise from the admission of air into the 
pleura of one lung, the other being diseased, or from large effusion of 
blood or of serum rapidly poured out into the pleural sac. But, as has 
been just stated, the majority of deaths from apncea are due to that 
gradual failure of the respiration which attends the exhaustion brought 
about by all severe diseases, and of which the quick laborious breathing 
and loud mucous rale (death rattle) are the well known indications. 
It is in this way that apoplectic seizures not sudden or violent enough 
to occasion death by asthenia, or shock, as well as most structural 
diseases of the brain, terminate. 



33 



CHAPTER III. 

PHYSIOLOGY AND GENERAL PATHOLOGY. 

136. The human body is a machine of finished workmanship, and vast 
variety of uses, infinitely surpassing the most perfect work of man's 
hands ; and containing within itself the means of ministering to its 
own growth and preservation, of repairing many injuries to which it is 
exposed, and of generating other machines of like structure and endow- 
ments. It is also a laboratory, in every part of which, at every 
moment, the most delicate chemical processes are being performed. 
This machine, with its exquisite mechanism and refined chemistry, is 
subject to change of place, to deprivation of the means of living, to 
violent death, or to slow decay, according to the dictates of a voluntary 
agent so dependent upon it, that all signs of his existence vanish before 
the last traces of its own vitality have disappeared. 

137. All the minute structures of this machine were believed to be 
built up, all its movements to be regulated, and all its chemical pro- 
cesses carried on, under the direction of a force, acting through a ma- 
chinery of its own, and manifesting its presence only by its effects. 
This force was called the " vital principle." It was thought to be an 
independent entity, a il/fX 7 ?? or sou ^ pervading the tissues and causing 
them to live ; and its disunion, or separation, from the body was death. 
But, according to a more modern theory, life is the collection of pheno- 
mena in organized beings, dependent partly on a certain structure and 
chemical composition, and partly on external agencies which stimulate 
them to action ; death ensuing when the structure is seriously damaged, 
or the external stimuli are withdrawn. 

138. On closer examination, the body is found to consist of the follow- 
ing parts : — A framework for locomotion and for the protection of its 
more important organs ; a digestive apparatus for the assimilation of 
its food ; organs of circulation for distributing the nutritious liquid 
blended with the pre-existing blood ; viscera for the secretion of fluids 
destined to further uses in the economy ; other viscera for the puri- 
fication of the blood, constantly being contaminated by the decom- 
position of the effete textures of the frame ; a nervous network bringing 
all the important internal organs of the economy into harmonious 
action ; and a nervous mass of brain and spinal cord, the centre of 
sensation, volition, and thought. 

D 



34 PHYSIOLOGY AND GEXEKAL PATHOLOGY. 

139. All these parts are most closely and intimately united ; so that 
if the heart ceased to circulate blood, or the lungs to purify it, the 
nervous system would no longer send forth those stimuli hy which the 
heart heats and the chest breathes. If, on the other hand, the nervous 
centres suffer severe injury, respiration is prevented or impeded, and 
the heart soon stops. External influences also, on whatever part they 
act, affect not that part only, but through it other organs, and through 
these the entire body. Again, the mind affects the body, and the body 
reacts on the mind, and both together form a being so intricate yet so 
perfect in structure, so complex yet so plastic in function, that the 
preservation of its health, and the continuance of its life, appear equally 
wonderful with its slow decay and certain death. But experience 
proves that the body is so constituted that while under favourable 
circumstances it enjoys the free play of all its parts, under unfavourable 
ones it is subject to serious derangements of function and alterations of 
structure. 

140. This brief outline will serve to indicate the following as the 
contents of the present chapter : — 

i. The physiology and general pathology of the fluids, including di- 
gestion, chylirication, sanguification, and excretion. 

ii. The physiology and general pathology of the circulating organs, 
considered as instruments for the distribution of the blood. 

iii. Structural physiology and pathology. 

iv. The physiology and general pathology of the nervous system. 

v. Mental physiology and pathology. 

I. PHYSIOLOGY AND GENERAL PATHOLOGY OF THE FLUIDS. 

141. Digestion, or the conversion of the food into chyme and chyle : 
the composition and properties of the blood and its constituents ; and 
the functions and secretions of the lungs, skin, kidneys, and liver, are 
the subjects to be considered under this head. 

142. — Digestion. — It is now well understood that waste of material 
is a condition of vital action ; so that every movement of the body, 
every thought, every act of volition, is attended by destruction or 
death of certain particles of the orgau concerned in the vital action. 
These particles being resolved into compounds unfitted to support life, 
are absorbed into the blood, and carried in the current of the circulation 
to organs destined for their separation and discharge. To supply their 
place is a principal use of our food. 

143. In an adult arrived at full growth, in perfect health and 

r, and using no undue exertion of mind or body, the daily waste 

paired by the daily food, and the weight of the body undergoes 

little or no change from day to day. But this nice balance of waste 

j be destroyed in many ways: — by increased exertion 

without proportionate increase of food ; by still stronger exertion, the 

appetite remaining good, and the Bupply of food unlimited ; or by in- 

exertion with diminished supply, as in training for the turf; 



WASTE AND REPAIR — HUNGER AND THIRST. 35 

or, lastly, with great rapidity, by entire abstinence. In all these cases 
the body loses weight. On the other hand, in healthy persons, with 
unimpaired digestion, it gains weight by inactivity, or, within certain 
limits, by increase of food. 

144. In certain diseases waste goes on with extreme rapidity ; as in 
fever, when rapid destruction of the textures is combined with com- 
plete loss of appetite ; in pulmonary consumption, when the local 
waste, added to profuse sweats or discharges from the bowels, exceeds 
the powers of assimilation ; in tabes mesenterica, in which the diseased 
glands refuse to transmit the chyle ; in diabetes, when mal-assimi- 
lation of the food checks the process of repair of even a moderate loss 
of substance ; during exhausting discharges, which drain the body of 
its blood ; and in some local diseases or injuries, attended by a loss of 
substance which the most nourishing diet cannot repair. 

145. During the period of growth food is required not merely to 
supply the waste due to the destruction of parts, but to furnish new 
material. Hence the large consumption of food in childhood and youth 
in proportion to the dimensions of the frame. 

146. One use of food, therefore, is to supply the waste constantly 
going on ; and in order that it may discharge this function, it must 
contain all those elements, simple and compound, organic and inorganic, 
which exist in the structure of the body. If the food is destitute of 
some essential element the health sooner or later suffers. The omission 
betrays itself in severe functional derangements, arrests of develop- 
ment, or well-marked structural lesions. Water is no less essential 
than the food into the composition of which it enters so largely. It is 
the largest constituent of the body, and cannot be withheld, even for a 
few days, without serious consequences. The loss of this essential element 
entails sensations of distress far more severe than those which attend 
the deprivation of food. 

147. The sensations of hunger and thirst warn us of this twofold 
waste of the solids and fluids, and invite us to repair it. 

148. In healthy temperate persons these sensations bear a just rela- 
tion to the wants of the frame ; but there are some diseases in which 
they give fallacious indications, and modes of life which blunt them, 
or render them unduly acute. 

149. A sensation of hunger disproportion ed to the wants of the 
frame is not uncommon. It is present in certain nervous disorders, in 
many cases of unsound mind, in some persons who lead an indolent 
and inactive life, and in rare cases it reaches a point of intensity known 
as Bulimia. The appetite, again, may be unduly stimulated by condi- 
ments, and by the arts of a refined cookery. On the other hand, it may 
be blunted by the use of opium, tobacco, and spirituous liquors in 
excess, disregarded during intense mental application, or prolonged grief, 
and destroyed by sudden emotion. It is also impaired or destroyed in most 
diseases, but especially in inflammatory and febrile disorders. 



36 PHYSIOLOGY AND GENERAL PATHOLOGY. 

150. The sensation of hunger, though usually a fair measure of the 
wants of the frame, sometimes deceives us as to its power of making a 
profitable use of food. In tabes mesenteriea, for instance, the body 
wastes through the obstruction offered to the passage of the chyle into 
the blood ; but, the stomach remaining sound, the appetite bears a due 
relation to the wants of the frame, and is often voracious. In the ad- 
vanced stage of the disease, when hectic fever sets in, the appetite and 
digestive power alike fail. 

151. The same observations hold good in respect of thirst: which 
may become disproportioned to the wants of the frame through the use 
of too stimulating a diet, salt meats, or spirituous liquors in excess. 
Intense thirst is also highly characteristic of the action of irritant 
poisons, partly due to inflammatory heat of the throat and fauces, and 
partly to the pressing necessity for the dilution of the poisoned blood. 
There is also a disease, the analogue of bulimia, known as Polydipsia. 

152. As, in a healthy state of body the appetite is an index of the 
amount of food required to repair waste, so, in certain diseased con- 
ditions, does its utter failure point out the expediency of total absti- 
nence. This is especially the case during severe febrile attacks, when, 
all the secretions being suppressed, and gastric juice no longer formed, 
digestion is rendered impossible, and indifference to food is heightened 
into positive loathing, or nausea. 

153. But though hunger and thirst, in a healthy person, and under 
ordinary circumstances, are accuiate indications of the wants of the 
frame, they are not so exact as to supersede the influence of habit ; for 
experience proves that a considerable latitude in the quantity of food 
and in the number of meals is quite compatible with sound health. 
Nature does not prescribe in a manner not to be mistaken either the 
quantity or the time. 

154. Nor is the kind of food best adapted to the wants of the frame 
indicated with such precision as to preclude the use of dietaiies varying 
greatly in different climates and among different races ; for though the 
form of the teeth is held to prove that man may partake both of animal 
and vegetable food, experience proves that a diet consisting chiefly or 
exclusively of the one or the other is consistent with perfect health 
and great strength. 

155. There is one period of life, however, at which the diet best 
suited to the wants of the frame is indicated in a manner not to be 
misunderstood, both by absence of the means of mastication and by the 
supply of the food itself; namely, the period of infancy. At this 
period a diet differing materially from that supplied by nature is often 
attended by fatal results. This is one of the causes of the high mor- 
tality during infancy, and especially in the first year of lii'e, of found- 
lings of children put out to nurse, and of the children of mothers com- 
piled to work for their living. 

156. The first step in digestion consists in the cutting and bruising 



THE SALIVA AND GASTEIC JUICE. 37 

of the solid portions of food by the teeth, the moistening of them by 
the saliva, and their propulsion into the stomach. The conditions of 
the perfect performance of this fiist act of digestion are, therefore, 
sound teeth, careful mastication, and sufficient saliva. Decayed teeth, 
and mastication imperfectly performed, either from habit, or from pre- 
occupation of the mind by study or business, are, therefore, very efficient 
causes of indigestion. 

157. The saliva, as has just been indicated, serves the purpose of 
moistening the food; but it has also the power of promptly converting 
starch into sugar, and this power it exerts on part of the starchy elements 
of our food. 

158. A portion of food thus bruised, moistened, and changed in 
composition, being received into the stomach, causes its muscular coat 
to contract, and promotes the secretion of the gastric juice. After an 
interval of a few seconds, the stomach relaxes to receive the next morsel. 
When the meal is finished, a peristaltic action of the muscular fibres sets 
in, commencing at the orifice of entrance (cardia), and extending through 
the entire organ, with greatly increased force and rapidity in the part 
nearest the orifice of discharge (pylorus). This peristaltic action takes 
place at short intervals till digestion is complete, and is such as to cause 
the food to rotate obliquely from above downwards, in two directions 
simultaneously: from the orifice of entrance by the orifice of discharge back 
to the entrance again. In this way the whole of the food becomes mixed, 
and exposed equally to the gastric juice. The part of the stomach near the 
orifice of discharge is meanwhile constricted, so as to form a sort of 
supplemental cavity, into which the fully-digested food is received, and 
out of which it is allowed to pass into the duodenum by occasional 
relaxations of the sphincter which closes the aperture of discharge. 

159. The gastric juice, under the stimulus of the food, is clear, 
transparent, without odour, slightly salt and perceptibly acid, the 
acidity being probably due to free lactic and hydrochloric acids. Its 
essential constituent is a peculiar principle called pepsin. It promptly 
disintegrates food, converts coagulated into soluble albumen, and checks 
putrefaction. It is poured out rapidly, in quantity proportioned to the 
food; but if the food exceeds the wants of the frame and the indications 
of the healthy appetite, part remains undigested, and undergoing decom- 
position, generates carbonic acid and other gases. 

160. When the food is solid or pulpy, the gastric juice acts on it 
almost immediately ; but when liquids in excess are taken with it, 
they must be removed by absorption before digestion can take place ; 
and this delay also favours dyspepsia. 

161. The time required for digestion in the stomach varies in differ- 
ent persons, and in the same person under different circumstances ; 
also with the quantity, quality, and consistence of the food itself, the 
quantity of liquid mixed with it, and the quantity of saliva. After a 
full meal an interval of four or five hours should elapse before taking 
fresh food. 



38 PHYSIOLOGY AND GENEEAL PATHOLOGY. 

162. The states of body and mind favourable to digestion are, repose 
and cheerfulness. Strong exeicise, and anxiety or preoccupation of 
mind, impair the power of the stomach. Short and long intervals 
between meals are also injurious; the one by overtasking, the other by 
wearying, the organ. 

163. The gastric juice, kept at the temperature of the organ and in 
motion, acts out of the body almost as well as in the stomach. If the 
temperature is much lowered, its power is greatly impaired, and when 
raised to 115° or 120° Fahr. is destroyed and cannot be restored. An 
artificial digestive fluid may be made by soaking the fresh mucous 
membrane of the stomach of an animal in dilute muriatic or acetic acid ; 
and if kept at a temperature of from 99° to 100° it converts food into 
a substance closely resembling chyme. 

164. Important facts relating to digestion, and the properties of 
different kinds of food, have been obtained by Beaumont, Londe, and 
others, who had opportunities of narrowly observing persons afflicted 
with fistulous openings into the stomach or small intestines. Their chief 
conclusions may be briefly stated as follows: — 1. Animal food is more 
completely digested than vegetable food, is retained longer, appeases 
hunger more completely, and is more stimulating. 2. Vegetable sub- 
stances leave the stomach with their texture only partially destroyed ; 
and when the wants of the system are not urgent, those that are 
most difficult of assimilation do not begin to be digested till they arrive 
at the ileum, though previously fully exposed to the action of the gastric, 
biliary, and pancreatic fluids. In the contrary case, the digestion of 
these substances takes place much more promptly. 3. When animal 
and vegetable food are taken together the vegetable portion leaves the 
stomach first. 4. The more cohesive the food the longer it remains in 
the stomach. 5. The more nutritive the food the longer does it continue 
in the stomach. 6. Fatty and oily substances are most difficult of 
digestion. 7. Boiled meats are more easy of digestion than roast, and 
roast than broiled. 

105. The leading constituents of the food are differently acted on by 
the gastric juice. Woody fibre, the husks and skins of fruit and grain, 
horn, hair, &c.,are not digestible; albumen is dissolved and so changed 
as to be no longer coagulated by heat ; fibrine and coagulated caseine 
are dissolved and partially converted into albumen ; sugar of milk be- 
comes changed into lactic acid, and starch into sugar. Fat and oil pass 
from the stomach unchanged, and, together with the amylaceous and 
saccharine matters which have not been acted on by the saliva and 
gastric juice, are reserved for the action of the bile and pancreatic fluid. 

166. Several attempts have been made to reduce the multitudinous 
ingredients of our food into two or three leading classes of elementary 
principles. All food, whether animal or vegetable, may be said to be 
resolvable, in addition to water and certain inorganic matters, into three 
principal classes — the saccharine, albuminous, and oleaginous. Milk, 






ELEMENTARY CONSTITUENTS OF THE FOOD — THE BILE. 39 

the nourishment provided for the young of animals, contains all these 
principles, and they exist in blood blended with certain effete matters. 

167. This threefold division was suggested by Prout ; but Liebig 
substituted two groups for three, and distributed all the organic con- 
stituents or elements into the nitrogenous and non-nitrogenous ; the 
first consisting of all those substances that can be resolved into the three 
gaseous elements, oxygen, hydrogen, and carbon, the second embracing 
all those which contain in addition the element, nitrogen. The non- 
nitrogenous group comprises fats and oils, gum, starch and sugar, spirits, 
wine, and beer. The nitrogenous group contains the seeds of plants 
and the blood and tissues of animals, and the albumen, fibrine, caseine, 
and other analogous principles, that may be separated from them. The 
first, or non-nitrogenous group, Liebig supposed to be heat-making or 
respiratory, the second tissue-forming or plastic. 

168. Albumen, fibrine, and caseine are constituents both of animal 
and vegetable matters ; and they resemble each other so closely in 
chemical composition that if albumen, fibrine, or caseine, be dissolved 
in a moderately-strong solution of caustic potash, and exposed for some 
time to a high temperature, we obtain from it, by adding acetic acid, the 
same gelatinous translucent matter, which on ultimate analysis yields 
about 56 parts of carbon, 22 of oxygen, 16 of nitrogen, and 7 of hydro- 
gen, in every 100, 

This is the proteine of Mulder ; of which a hundred parts, with one 
of phosphorus and two of sulphur, constitute albumen, as found in the 
serum of the blood ; with one of phosphorus and one of sulphur, fibrine : 
and with one of sulphur, caseine. The other proximate organic princi- 
ples, gelatin, chondrin, elain, stearin, margarin, haematosin, globulin, 
&c, also consist of the four elements (nitrogen, carbon, oxygen, and 
hydrogen), in different proportions, with or without phosphorus and 
sulphur. 

169. The food, then, before it leaves the stomach, undergoes a two- 
fold process of reduction and conversion. It is submitted to a chemical 
action, by which starch is changed to sugar, and albumen, with sub- 
stances of analogous composition, is rendered soluble ; and it passes, as 
a homogeneous pulp, under the name of chyme, into the duodenum, 
where it is largely diluted, and submitted to further chemical changes 
by fluids poured into it from the liver and pancreas. 

170. The bile may be briefly described as a thin soapy fluid, which 
has the property of reducing fats and oils to a state favourable to 
absorption, of precipitating the albuminous matters previously rendered 
soluble by the gastric juice, and of neutralising, by its alkaline con- 
stituents, the free acid of the chyme. But when mixed with gastric 
juice out of the body, or when it regurgitates into the stomach, it 
arrests the process of digestion. It also acts as a stimulus to the 
intestinal canal, promoting both its secretions and the action of its 
muscular walls. 



40 PHYSIOLOGY AND GENERAL PATHOLOGY. 

171. The 'pancreatic fluid seems to combine the properties of the 
saliva, gastric juice, and bile; for it converts staich into sugar, dis- 
solves albuminous matters, re-dissolves the a bunien piecipitated by the 
bile, changes fatty and oily matters into an emulsion, and is, therefore, 
fitted to complete whatever of digestion the other fluids have left in- 
complete. 

172. As one function of the r p ancrea t lC fluid is to dissolve fatty 
matters, the discovery of such matters in the stools affords a strong 
probability in favour of some disease of the pancreas arresting its secre- 
tion, or impeding its discharge into the bowel. 

173. The action of the pancreatic fluid ends here ; but the bile ap- 
pears to play an important part in the economy by subserving the func- 
tion of respiration ; its principal constituents, taurin, cl-olic acid, and 
glycocin, and the sugar which has been proved to exist in the blood of 
the hepatic vein, being rich in carbon, and having a strong affinity for 
oxygen. 

174. These highly-carbonised constituents of the bile in their passage 
through the intestines are taken up by the lacteals and poured into the 
stream of blood ; a small part (estimated at a thirty-fourth part of the 
entire secretion) being rejected fiom the body in the faeces ; while the 
saccharine matters in the hepatic vein pass direct into the ascending 
cava, enter the heart, and circulate through the lungs. 

175. The foetal liver doubtless performs analogous functions. The 
bile is secreted, and poured into the intestines, as in the adult: that 
portion which is fitted to form part of the circulating fluid is absorbed; 
while that which in extra-uterine life mixes with the undigested rem- 
nant of the food and other effete matters, and is periodically discharged 
from the bowels as fceccs, collects in the intestines as meconium, and is 
expelled soon after birth or during delivery. 

176. The bile stands alone in being secreted from blood that has 
already served other purposes in the economy. As the vena portae is 
mainly formed by tributaries from the intestines, it suffers distension 
whenever their coats are congested. So that while the quantity of 
bile depends on the supply of blood from the intestines, the intestinal 
vessels are filled or emptied, and the functions of the intestinal canal 
promoted or hindered, by free action or toipor of the liver itself. 

177. The gall-duct which conveys the bile into the duodenum also 
performs the part of a safety-valve to guard against the gorging of the 
liver and lungs with bloo.l, as is proved by the discharges of blood that 
occur in extieme cases of congestion of the liver, whether connected or 
not with a similar state of the lungs; as also by the laige quantities of 
bile, discharged into the duodenum and regurgitating into the stomach, 
or carried forward through the intestines, in certain cases of bilious 
vomiting and diarrhoea, in phthisis pulmonalis, and in diseases of the 
lungs, functional and organic. In cold climates, a sedenlaiy life, giving 
little play to the Lungs, conjoined with indulgence in the pleasures of 



CAUSES OF DIAERHCEA AND CONSTIPATION. 41 

the table, leads to an increased secretion of bile, part of which, passing 
into the intestines, doubtless tends to prevent pulmonary congestion, 
and part, being absorbed into the blood, tinges the conjunctiva and 
skin. Strong exercise in the open air, by calling the lungs into activity, 
lessens the necessity for the formation of bile, rapid y removes symptoms 
of indigestion, and restores the natural clearness of the complexion. In 
hot climates again, the demand upon the lungs for the combustion of 
the carbon and hydrogen of the blood being diminished, if more nourish- 
ment be eaten than is required, bile is formed in increased quantity. 
In either case (whether in cold or hot climates), habitual excess in 
eating and drinking, ;md especially the free use of the liquid hydro-car- 
bons (the several forms of spirituous liquor), leads to the same result — 
functional or organic disease of the liver. 

178. The intermediate position of the liver — between the lungs 
(through the light cavities of the heart), and the intestines (through 
the vena portse), accounts for the frequency of functional and organic 
diseases of the liver, which occur as indirect consequences both of pul- 
monary and of intestinal disorders. 

179. The chemical process of digestion carried on successively by 
the saliva, the gastric juice, the bile, and the pancreatic fluid, is not 
completed in the duodenum, but continues throughout the small intes- 
tines, and is probably finally completed in the caecum by the solution 
of the last undigested portions of vegetable matter. 

180. As the food blended with the secretions of the mouth, stomach, 
liver, and pancreas, passes through the long tract of the small intes- 
tines, its nutritious portions are removed by the lacteals, and the 
residue passes into the large intestines, from which, after the absorption 
of some of its liquid constituent?, it is discharged as fceces, amounting 
in quantity to about 1-1 8th part of the food taken. 

181. The indigestible part of the food mixed with the residuum of 
the bile,foims the natural stimulus to the movements of the intestinal 
canal; an excess of bile increasing the peristaltic action, a deficiency of 
it, whether through diminished secretion or obstructed flow, causing 
constipation. In like manner, an excess of undigested or ill-digested 
matters, produces diarrhoea; and the absence of all indigestible matter, 
one of the evils of an over-refined cookery, causes constipation. The 
passage of the fasces through the intestines is also greatly promoted by 
the movements of respiration, and by all exercises in which the abdo- 
minal muscles are called into play. Sedentary habits, on the contrary, 
promote constipation. 

182. Of the two parts into which the chyme is separated, viz., 
chyle and fseces, the chyle is absorbed by the lacteals, and conveyed 
into the thoracic duct, where it mixes with the lymph collected from 
all parts of the body by the absorbents. This mixed fluid, after 
undergoing changes in its course through the lacteals by which the 
quantity of albumen is greatly increased, is poured into the left sub- 



42 PHYSIOLOGY AND GENERAL PATHOLOGY. 

clavian vein, and becomes part of the blood. The absence of these 
changes is supposed to lead in children to obstruction of the mesenteric 
glands, and, later in life, to the deposit of an imperfect albumen mixed 
with fatty or earthy matters, constituting scrofulous matter, tubercle, 
and other morbid deposits. 

183. To the changes which the food undergoes from its reception 
into the stomach till it is mingled, in the form of chyle, with the blood, 
Prout gave the name of primary assimilation. Those that take place 
in the capillaries during the formation of new parts, and the conversion 
of effete structures into lymph ; and those also which the contents of 
the absorbents themselves undergo, he called secondary assimilation. 

184. Both these processes may be imperfectly performed. In the 
primary process some one constituent of the food may be imperfectly 
acted on. The mal-assimilation may be limited to the saccharine 
principles (sugar and lactic acid, starch and gum; causing the formation 
of sugar, which finds its way into the blood and urine in diabetes ; of 
oxalic acid, which, in union with lime, constitutes the oxalate of lime, 
or mulberry calculus ; and of lactic acid, which abounds in rheumatic 
and hectic fevers, and is probably the chief ingredient in the acid 
liquors discharged from the stomach in dyspepsia. Mal-assimilation 
of the albuminous principles (albumen, gelatin, fibrin, and gluten) 
may lead to an excess of albumen, conveyed into the blood and elimi- 
nated by the kidneys, and to the formation of lithic acid and cystic 
oxide calculi ; that of the allied gelatinous principles leads to an excess 
or deficiency of urea, or of its equivalent, carbonate of ammonia; while 
the mal-assimilation of the oleaginous principle leads to a deficiency of 
fat in the frame, or leanness ; and an unusual power of assimilating 
this principle, to corpulence. 

185. These forms of mal-assimilation are inferred to exist, not so 
much from the analysis of substances rejected from the stomach, or 
contained in it after death (though sugar has been found in the stomach 
in excess in cases of diabetes;, as from discovering the products of such 
mal-assimilation in the blood and urine. 

186. The precise nature of the changes that take place in the capil- 
laries and in the absorbents (secondary assimilation} cannot be deter- 
mined by direct observation, but must be inferred from the composition 
of the blood, on the one hand, and of the various excretions on the 
other. In the formation of the several secretions and structures of the 
body, the blood is robbed of some of its chief constituents, such as 
fibrin, albumen, and salts, while, on the other hand, it is tainted by 
the products of the destruction of the effete and useless parts of the 
frame, containing many new principles destined for removal by the ex- 
creting organs, and which, if not so removed, act as poisons, and give 
rise to serious diseases. 

187. The principal structures of the body are the albuminous and 
the rjclatinous. The albuminous structures which in health are re- 



THE BLOOD — ITS COMPOSITIOX. 43 

solved into lithate of ammonia, when mal-assimilated give rise to lithic 
acid gravel, and perhaps to certain poisonous combinations of cyanogen. 
During this imperfect assimilation certain diseases of the albuminous 
tissues are supposed to arise. The gelatinous tissues which in health 
are resolved into lactate of urea, when mal-assimilated, are converted 
into sugar and urea, or into oxalic acid and urea, the urea being re- 
placed in either case by carbonate of ammonia. The mal-assimilation 
of these textures also leads to certain diseases of the skin, and to de- 
structive suppuration of the cellular tissue. 

188. The food has now been traced through the successive mecha- 
nical and chemical processes of digestion to its mixture, as chyle, with 
the mass of the circulating fluid. How the milk-white contents of the 
thoracic duct are converted into red blood, or, to speak more precisely, 
how the red globules which are superadded to its colourless constituents 
are formed out of the materials supplied by the lymph, is not exactly 
known. It has, however, been shown that the lymph itself contains 
lymph-corpuscles differing from the red particles chiefly in colour, and 
probably destined to form the groundwork of them. 

189. The Blood. — This fluid, as it circulates in the vessels, is of very 
mixed character, for it is being constantly renovated by chyle derived 
from the food, and contaminated by lymph absorbed from the tissues ; 
so that it contains all the materials required for their formation, 
nourishment, and growth, and also all the new elements into which 
they are resolved when no longer fit to form parts of the living 
frame. 

190. The quantity of blood in the body of an adult has been 
variously estimated at from 8 to more than 30 pounds. The quantity 
which can be made to flow from the corpse of a decapitated criminal, 
added to that which can be washed out of its vessels, is about an 
eighth of the we : ght of the body itself. This, the highest ascertained 
proportion, would give 20 pounds of blood for an adult weighing 160 
pounds. The quantity must, however, be subject to variation. It is 
at its maximum within a few hours of a hearty meal, at its minimum 
after long abstinence. 

191. The specific gravity of the blood is about 1055. It may reach 
1059 in robust men, and fall as low as 1050 in women; in pregnant 
women as low as 1045. It is also low in very young infants. Its 
temperature is about 100° Fahr. Its colour a bright red in the arteries, 
and dark red in the veins. It is fluid when circulating in the living 
textures, but coagulates in from three to seven minutes after removal 
from the body. 

192. The blood consists of red particles or corpuscles, to which it 
owes its colour, of colourless finely granular cells (white corpuscles) 
and of transparent colourless serum, holding fibrine in solution, and 
known as liquor sanguinis or plasma. The red corpuscles which 



44 PHYSIOLOGY AND GENERAL PATHOLOGY. 

form half its bulk have the high specific gravity of 1088. The white 
corpuscles bear to the red the proportion of 1 to 1 00. 

193. The blood in coagulating separates into two parts, the crassa- 
mentum, or clot, and serum. The clot is formed by coagulated fibrine 
enveloping the red and white corpuscles and part of the serum ; and 
its consistence depends on the relative quantity of these constituents. 
When the fibrine is large in proportion the clot is firm ; when there is 
much serum, it is loose. 

194. When blood-letting was being constantly employed as a remedy, 
it was usual to examine the blood, with a view to ascertain the state of 
system in which the remedy had been prescribed; and ceitain appear- 
ances in the clot were held to prove the existence of inflammation. 
The importance of this procedure has diminished bs a resort to the 
lancet has become less common ; but the phenomena of coagulation still 
merit attention. 

195. The appearance supposed to indicate inflammation, to justify 
the past abstraction of blood, and to warrant a fresh recourse to the 
lancet, was a concave and buff-coloured clot. When it presented both 
these characters, it was said to be buffed and cupped. 

196. Healthy blood drawn from a vein, and suffered to remain at 
rest, undergoes two principal changes, the subsidence of a portion of its 
red particles, and a coagulation of the mass of the fluid. The red 
particles begin to subside as soon as the blood is drawn : coagulation 
rapidly follows, and in about ten minutes converts the blood into a 
loose jelly. The blood, thus transformed from a homogeneous fluid into 
a nearly homogeneous solid, undergoes a further change, often not 
completed within twenty-four hours, or even more. This consists in 
the progressive contraction of the fibrine in the lower part of the 
mass, so as to entangle the red and white corpuscles, and press out the 
serum. Hence, the upper layer of the clot contains no red particles, 
but consists wholly of the buff-coloured liquor sanguinis, hollowed or 
cupped by the strong contraction of the fibrine ; and as the lower por- 
tion, which consists of fibrine and red particles, is larger and looser, the 
outline of the clot is not unlike a cupping-glass. 

197. From this statement it follows, that the size, shape, and 
colour of the clot may be influenced by more causes than one. If the 
red particles retain their natural specific gravity, while that of the 
liquor sanguinis is diminished, or if they have a greater specific gravity 
than usual, whilst the liquor sanguinis has its normal density, or, again, 
if they have an unusual tendency to coalesce and adheie (as has been 
shown to be the case in inflammation), they will sink rapidly, and the 
separation between the upper and lower parts of the clot will be com- 
plete. The opposite conditions of the two portions will, of course, pro- 
duce opposite le.^ults. Again, the contractility of the fibrine being the 
same in two cases, if the quantity i.> increased in the first and lessened 
in the second, the clot will be large in the one, and small in the other. 



THE BLOOD — THE RED CORPUSCLES. 45 

If, the quantity of fibrine remaining the same in two cases, the contrac- 
tility is great in the first and small in the second, the cupped appear- 
ance will be present in the one, but absent in the other. The thick- 
ness of the burled surface will depend on the quantity of the liquor 
sanguinis separated from the rest of the clot ; which, in its turn, will 
vary with the time that elapses before the fibrine begins to contract. 
The slower the coagulation, therefore, the thicker the buffy coat. 
Again, a great diminution in the quantity of the red particles would 
favour the complete separation of the liquor sanguinis, and give rise 
to the buffy coat. 

198. The separation of the liquor sanguinis and the degree of con- 
traction of the fibrine are influenced by many causes, such as the size 
of the stream, the depth of the vessel, the temperature of the blood 
itself, and of the place in which it is kept, its exposure to the air, and 
even the shape of the vessel into which it is drawn. 

199. In the experiments of M. Andral and others, a cupped and 
buffed appearance of the blood has been observed in diseases unaccom- 
panied by inflammation, as in chlorosis, in which disease it was present 
in sixty-four per cent, of the cases. 

200. The buffy and cupped coat, then, is no sure indication of 
inflammatory action, but only of an alteration in the relative quantities 
of the fibrine and red corpuscles, or an excess, either absolute or 
relative, of the fibrine. 

201. The quantity of the crassamentum, or clot (the combination of 
fibrine and red globules with a variable proportion of serum) varies 
within wide limits ; the blood of men being more rich in the chief 
constituents of the crassamentum (fibrine and red corpuscles) than 
that of women : and in persons of the sanguine temperament than in 
the lymphatic. 

202. The quantity of red corpuscles differs in different persons at 
different times, and it probably varies with age, sex, temperament, and 
state of health. According to Becquerel and Rodier, it ranges between 
113 and 152 parts in a thousand ; the average for healthy males being 
141, and for healthy females 127. 

203. The red corpuscles are biconcave discs, consisting of a capsule, 
inclosing a homogeneous, faintly granular, semi-fluid, red-tinted sub- 
stance. When the blood is mixed with water the particles swell by 
imbibition ; but if mixed with syrup, or a liquid of greater specific 
gravity than the blood, they shrink and become puckered from the 
exsudation of their liquid contents. It is probable, therefore, that 
by swelling when the specific gravity of the blood is reduced, and 
shrinking when it is increased, the red particles may serve to maintain 
a more uniform consistence of the circulating fluid. 

204. The red corpuscles are variously affected by chemical agents 
and by some of the secretions. The bile completely dissolves them. 



-16 PHYSIOLOGY AND GENERAL PATHOLOGY. 

205. The fibrine in healthy blood varies from 1 j to 3 J parts in a 
thousand, the average being 2i. It is more abundant in arterial than 
in venous blood, in about the proportion of 5 to 4. 

206. The serum is a straw-coloured fluid, holding albumen in solu- 
tion. When heated to 167° Fahr., the albumen ccngulates, and sepa- 
rates, and this change takes place equally when the serum is mixed 
with other liquids, such as the urine : so that heat detects the presence 
of serum in the urine, and the existence of a certain form of disease of 
the kidney. 

207. The fluid remaining after N the separation of the albumen is 
called the serosity. It consists of extractive matters and inorganic salts 
(principally of soda) dissolved in water. 

208. The several constituents of the serum vary with sex, age, and 
temperament. The quantity of v:ater is greater in females than in 
males ; in children and aged persons than in persons of middle age ; and 
in the lymphatic temperament than in the sanguine. In healthy males 
it has a range of from 760 to 800 parts in a thousand, and an average 
of 779 ; and in healthy females, a range of 773 to 813, with an average 
of 791. The albumen ranges from 62 to 75 parts in a thousand, the 
average being about 70. 

209. Besides the constituents just mentioned, the blood contains, in 
minute quantity, a variety of matters destined to be removed from the 
body by the excreting organs, especially the kidneys. When these excre- 
tions are checked, these matters accumulate in the blood, and may be 
detected by chemical reagents. 

210. The blood undergoes various changes in disease: — (a) Sensible 
changes ; (6) Variations in the proportions of its constituents ; (c) Ad- 
mixture of substances foreign to its healthy composition. 

211. (a) Sensible changes. — The quantity of blood is increased by 
taking food and in plethora, and diminished by haemorrhage and absti- 
nence. It is also said to be diminished in anaemia ; but the pallor which 
characterises that disease may be explained by a deficiency of red cor- 
puscles. Its temperature is increased in diseases accompanied by a 
rapid circulation, such as severe inflammations and inflammatory fevers : 
on the other hand, it is lowered in languid states of the circulation, 
and especially when the blood is imperfectly decarl ionised, as in apncoa, 
poisoning by prussic acid, cholera, and cyanosis. The colour of the blood 
is more florid in the cases in which its temperature is raised ; and darker 
in those in which its temperature is lowered. It is changed from dark 
blue to black by contact with acids, whether formed in the body itself 
or introduced from without; and it has been described as having a 
glimmering blue tint in some cases of poisoning by prussic acid. 

212. (b) Variations in the relative proportions of its constituents. 
— The red corpuscles are in excess in plethora, and in defect in anaemia. 
The white corpuscles abound in anaemia. They are slowly reproduced ; 



PRODUCTS OF MAL- ASSIMILATION. 47 

hence the long continuance of pallor after haemorrhages. The flhrine is 
increased in acute inflammations, especially of the serous membranes, in 
acute rheumatism, pneumonia, phthisis, erysipelas, cynanche tonsillaris, 
and absorbent inflammation. The greatest increase takes place in acute 
rheumatism, being sometimes nearly three times as great as in health, 
and continuing in excess after repeated bleedings. It is also iu excess 
in the pregnant female. On the other hand, its quantity is diminished 
in fevers which are not inflammatory, in cerebral congestions and 
haemorrhages, in scurvy, in profuse haemorrhages, and in inflammation 
of the mucous membranes. The quantity of the serum increases as 
that of the clot diminishes. The quantity of vmter in like manner in- 
creases as that of the more solid ingredients decreases. It is in excess 
in anaemia, and in chronic exhausting maladies. The albumen probably 
bears a near proportion to the nbrine : it is greatly diminished in cases 
of Blight's disease. The salts of the serum are diminished in typhoid 
fever, and in cholera morbus. 

213. These facts are stated chiefly on the authority of Andral and 
Gavarret,* to whom we are indebted for the following table of the 
variation observed in the quantity of the chief constituents of the blood 
in disease, compared with the average in health. 

Fibrine varies between 10^5 and 0*9 per 1000 parts — average in health 3 

Globules . . .185 21 127 

Solid matters of serum 114 57 80 

Water . . .915 725 790 

Inorganic matters of 
serum ...8 5 8 

214. (c) Admixture of substances not found in healthy blood. 1. 
Results of mal-assimilation of the food. 2. Elements of the natural 
secretions and excretions. 3. Morbid secretions of the blood itself; 
and 4. Poisons introduced from without 

215. — 1. Sugar is sometimes found in undue proportion in the 
blood as the result of mal-assimilation in the stomach, and oxalic acid 
found in combination with lime in the urine, is presumed to have 
existed as such in the blood itself. 2. The elements of the secretions 
and excretions accumulated in the blood, in consequence of disease of 
the excreting organs, or of their excessive production during primary 
and secondary assimilation, are chiefly the following : urea, lactic acid, 
fatty matter in excess, colouring matter of the bile, cholesterin, free 
carbonic acid, and casein. 3. Of the morbid secretions of the blood 
itself, the chief is pus, which, under certain circumstances, is absorbed 
from the veins or from suppurating surfaces, and carried into the cir- 
culation. 4. Poisons introduced into the stomach, by wounds, or by 
the unbroken skin, rind their way into the blood, and may be detected 
there by appropriate tests. 

216. The constituents of the blood may be separated and thrown 
out among the textures of the body, or on the surface of membranes, or 

* Annales de Chimie et de Physique, Nov. 1840. 



48 PHYSIOLOGY AND GENERAL PATHOLOGY. 

discharged by the several outlets. Fibrine plays an important part in 
every process of reparation ; water and serum are formed in the sacs of 
serous membranes, and in the cellular tissue ; and the red corpuscles 
escape in peculiar states of debility. In inflammation, accompanied by 
loss of substance, a new liquid (pus) is formed. 

217. The chyle and lymph which are constantly being added to the 
blood bring with them many useful and some hurtful principles which 
must be discharged from the body. The principal organs by which 
this is effected aie the lungs, skin, kidneys, liter, and intestines. 

21 8. Respiration. The air-tubes, after repeated divisions and sub- 
divisions, terminate in small vesicular cells, on the walls of which a 
network of minute blood-vessels is distributed. The membrane of 
these cells, through which the atmosphere acts on the blood, is believed 
to be at least thirty times as extensive as the surface of the body. The 
lungs, therefore, constitute one vast excreting surface, from which there 
constantly escapes into the air a mixed cloud of carbonic acid gas and 
water. An interchange of carbonic acid and oxygen takes place through 
the membrane of the cells, by which the one is released and the other 
absorbed, the absorption of oxygen changing the colour of the blood 
from dark blue to light red. 

219. Viewed as excreting organs, the lungs have this peculiarity, 
that they require for the due performance of their functions the con- 
tact and constant renewal of atmospheric air. This is brought about 
by the alternate expansion and contraction of the walls of the chest, 
coinciding with the depression and elevation of the diaphragm, which 
movements in healthy and well-formed adults are repeated about eighteen 
times in a minute. 

220. The lungs are always expanded by air. After ordinary expira- 
tion, it is believed that as much as 108 cubic inches of air remain ; 
and it is probable that the quantity subject to change does not exceed 
15 cubic inches. At this rate, if we suppose the number of respira- 
tions to be twenty in the minute, no less than 432,000 cubic inches, or 
250 cubic feet, of air will be required to support the function of respi- 
ration during twenty-four hours. But if the body were to remain at 
rest during the whole of that time, the consumption of air would not 
be so great. 

221. But from a calculation based on the assumption that 10 J ounces 
of carbon are eliminated from the lungs and skin of an adult male in 
twenty-four hours, it may be inferred that the quantity of air required 
during that time (no portion being used more than once), falls little 
short of 2000 cubic feet; so that if a man were shut up in a perfectly 
close apartment, opened only once every twenty-four hours, he ought 
to have that space allotted to him. On the same principle, a close 
bedroom occupied during a night of eight hours, ought to have nearly 
700 cubic feet of air for each adult male occupant. This space may be 
safely curtailed where sufficient ventilation is practised ; but the space 



RESPIRATION — QUANTITY OF CARBONIC ACLD. 49 

allotted to each adult during twelve hours, whether by day or night, 
ought not to fall greatly short of 1000 cubic feet, that is to say, a cube 
10 feet in every dimension. In buildings for the reception of the sick, 
this quantity should be increased at least one half. In apartments 
occupied for shorter spaces of time, 75 cubic feet per hour "would be a 
sufficient allowance. The quantity may be reduced in the case of adult 
females and young and aged persons of either sex ; and a less amount 
will suffice in hospitals and public establishments in the country than 
in similar institutions in large towns. 

222. The air drawn into the lungs at each inspiration has been just 
taken at 15 cubic inches; but this is probably too low an estimate. 
Yierordt found that, in his own person, the quantity at one time was 
nearly five times as great as at another, the minimum being 11, an ave- 
rage of the maxima 43, and the mean of all his observations 31 ; and 
Valentin, by experiments on young adult males, whose respiration was 
tranquil, or only somewhat quickened, obtained a minimum of 14, a 
maximum of 95, and a mean of 40 cubic inches. The principal experi- 
menters on respiration give estimates or measurements founded on ex- 
periment, ranging from a minimum of 12 cubic inches (Goodwyn and 
Abernethy), to a maximum of 40 cubic inches (Turin and Menzies). 

223. According to the lowest estimate, the carbonic acid formed in 
twenty-four hours amounts to 14,930 cubic inches, or 8,534 grains ; 
according to the highest, to 39,600 cubic inches, or 18 s 612 grains. 
The mean of the three estimates (Lavoisier and Seguin, Davy, and 
Allen and Pepys) is nearly 28,736 cubic inches, or 14,985 grains. The 
quantity of carbon removed from the blood will therefore be, according 
to the lowest estimate, 2,820 grains, according to the highest, 5,148, 
and the mean of the three estimates will give 4,273 grains, or nearly 
10 ounces avoirdupois. This estimate falls short by a quarter of an 
ounce of that given by Dalton. Liebig found that an adult taking 
moderate exercise expires daily from the lungs and skin an average of 
13'9 ounces of carbon. 

224. Air once respired contains nearly 5 per cent, carbonic acid ; but 
however frequently the same air is breathed, it never contains more 
than 10 per cent. The respired air is diminished by about J ? th of its 
volume ; probably through the absorption of oxygen, When pure 
oxygen is breathed, the carbonic acid given off from the lungs is 
increased. 

225. Prout's experiments show that more carbonic acid is generated 
in a given time between 11 a.m. and 1 P.M. than between Sh P.M. and 
3| A.M. ; and more during the day than at night. Less carbonic acid 
is formed in females than in males ; in young and old than in middle- 
aged persons. It is increased by repletion and exercise, lessened by 
fasting and rest. It is also diminished by depressing passions, by fatigue, 
by spirituous liquors, tea, or vegetable i'ood, and by the long-continued 
use of mercury. It is also given off in larger quantity when the baro- 
meter and thermometer are low. 



50 PHYSIOLOGY AND GENERAL PATHOLOGY. 

226. The water exhaled from the lungs in twenty-four hours 
amounts, according to different estimates, to from 2,880 to 13,704 
grains, or from about 6} ounces to 1 pint 11 ounces. 

227. The chief function of the lungs, then, is to free the blood from 
carbonic acid and water. The separation of carbonic acid, and the 
absorption of oxygen, are necessary to enable the blood to nourish the 
body, and to act as the efficient stimulus to all its functions. The 
suspension of breathing for a few minutes is fatal to life, and the cir- 
culation of blood not purified by respiration has an injurious influence 
on all the organs, but particularly on the nervous system. 

228. The carbonic acid exhaled from the lungs is greatly increased in 
the first stage of small-pox, measles, and scarlatina, as well as in various 
chronic diseases of the skin, but it is diminished in typhus fever. 

229. The lungs also serve as channels through which many volatile 
matters taken into the stomach escape almost unchanged; and the 
sweet breath of some healthy persons and the tainted breath of cachectic 
patients proves that those organs may also serve as avenues through 
which volatile matters formed within the system, and circulating with 
the blood, find their way out of the body. Bernard's experiments also 
prove that sulphuretted hydrogen introduced into the circulation escapes 
from the body through the lungs. 

230. The Sweat. — The Skin performs two important functions ; ft 
separates from the blood matters which would be injurious if retained in 
it, and it regulates the heat of the body by the discharge of water. 
The chief constituents of the sweat are carbonic acid, nitrogen, ammonia 
combined with lactic acid (according to some, with acetic acid), urea. and 
a variety of salts. 

231 . The carbon eliminated by the skin in twenty-four hours amounts, 
according to Dalton, to a quarter of an ounce, being but a small frac- 
tion of that given off from the lungs. Sometimes carbonic acid is 
exhaled with nitrogen, sometimes nitrogen alone is given off, and at 
others neither of them is present. The quantity of these gases also 
varies considerably with the quantity of food and the amount of mus- 
cular exertion. Nitrogen is most abundant after animal, and carbonic 
acid after vegetable, food. 

232. The exhalation from the skin amounts, according to Dalton's 
estimate, to 0J ounces in twenty-four hours. The more accurate expe- 
riments of Seguin give 7 grains per minute in a male ill a state of rest, 
or little less than 1J lb. in twenty-four hours. 

The aqueous exhalation is partly mere evaporation, and partly a 

secretion. Thi on is due to common physical causes, and is 

increased by a dry and warm atmosphere, by air in motion, and by 

diminished pressure of the air; lessened by moist and still air, and by 

I atmospheric pressure. The secretion is increased by moderate 

ment of the circulation, and diminished by rest. 



SECKETIOXS OF THE SKIN AND KIDNEY. 51 

234. The perspiration is diminished when other secretions are greatly 
increased : thus the skin is dry in diarrhoea, diabetes, cholera, and dropsy. 
It is also diminished in the cold stage of intermittent and continued 
fevers, and at the commencement of all febrile affections, as well as 
in acute inflammations, in the hot stage of fever, and in the febrile exan- 
themata. In the first class of cases a small quantity of blood circulates 
through the vessels of the surface ; in the second, the circulation is 
increased beyond the secreting point. 

235. On the other hand, the perspiration is increased in the sweating- 
stage of intermittent fevers ; in mild continued fevers ; in catarrhal 
and miliary fevers ; and in inflammatory affections of moderate severity. 
It is also increased whenever determination of blood to the ?kin is com- 
bined with debility of the capillaries, as in the hectic fever of phthisis 
pulmonalis and other exhausting maladies. In extreme debility, again, 
the perspiration is augmented through the weakness of the capillary 
vessels, though the quantity of blood circulating through them is 
diminished. Such are the cold sweats of the dying. The perspiration 
is also very abundant in acute rheumatism, and in hypertrophy of the 
heart. 

236. The odour of the perspiration appears to be compounded of a 
sourness due to lactic and acetic acids, and of a peculiar animal odour 
perceptible in bedrooms, in rooms recently occupied by bodies of men, 
and in most persons after laborious exertion. The sour odour pre- 
dominates in some, the animal odour in others. The first is heightened 
in catarrhal, rheumatic, and arthritic diseases, in childbed, and in inter- 
mittent fevers ; the last in pulmonary consumption, and in many 
persons of unsound mind. 

237. Sweats are sometimes partial, as in phthisis ; sometimes 
general, as in the sweating stage of fevers ; and partial sweats pass 
into general ones. 

238. Remedies act on the skin chiefly through the circulation, some 
by diminishing, others by increasing the heart's action. The passions 
of the mind also affect the secretion from the skin, by exciting or de- 
pressing the action of the heart, agreeable emotions producing a warm 
moist glow, the stronger depressing emotions, copious cold perspirations. 

239. The Urine. — The kidneys subserve the twofold purpose of 
relieving the system of excess of water, and of removing (in suspension 
or solution) solid matters which have been taken as food, or have re- 
sulted from the disorganization of the nervous and muscular tissues. 
These last occur under the form of urea and uric acid, and certain sul- 
phates and phosphates. The urine is also the channel for the removal of 
medicines and poisons. 

J240. The quantity of urine excreted in twenty-four hours varies ac- 
cording to the activity of the skin : 48 ounces is about the average. 
Whatever be the quantity, it should contain about 1 ounce of urea. 



OZ PHYSIOLOGY AND GENERAL PATHOLOGY. 

241. The most important constituents of urine are water, urea, and 
uric acid. The two latter ingredients consist of the following: elements : — 





Nitrogen. 


Carbon. 


OxygeD. 


Hydrogen. 


Jrea 


47 


20 


27 


7 


Jric acid . . 


31 


40 


27 


2 



Urea and uric acid, therefore, contain so large a proportion (urea 
nearly fifty per cent.) of nitrogen, that they are the principal means 
by which this gas is eliminated from the system. They vary with the 
quality of the food, being increased by animal and diminished by 
vegetable diet ; they are almost absent in infants at the breast ; and go 
on increasing towards manhood. 

242. The quantity of the urine is increased by the suppression of 
other secretions, and lessened by their increase : and this is specially 
true of the cutaneous exhalation. As the urine attracts special atten- 
tion at the bedside, it will be more minutely examined in the next 
chapter. 

243. TJie Bile. — This secretion has been well described as a soapy 
solution of two peculiar fatty acids combined with soda, forming the 
so-called glycocholate and taurocholate of soda. These, dissolved in 
about nine times their weight of water, constitute about nine-tenths 
of the solid constituents of the secretion, every hundred parts of 
which contain 64 of carbon, 9 of hydrogen, 3 of nitrogen, and 24 
of oxygen. The quantity of bile formed in twenty-four hours has 
been estimated at from 17 to 54 ounces. U\ in the absence of 
precise data, we take the quantity at one pint, and suppose it to 
weigh 9000 grains, it follows that, as the solid constituents form 
one-tenth of the entire secretion, their weight will be about 900 
grains. As, again, nine-tenths of these solid constituents consist of 
taurocholic acid, it follows that about 810 grains of this substance are 
secreted daily. Now 64 parts in 100, or rather more than three-fifths 
of this, consist of carbon. This will give for the carbon contained in 
the bile nearly 520 grains ; and as the bile daily voided with the 
faeces does not weigh more than a scruple, upwards of an ounce of 
carbon must find its way into the intestines, to be absorbed and 
carried into the circulating system as prepared fuel for the lungs 
(§ 170, et seq.). Hydrogen, to the amount of about a seventh of this 
quantity, would have to be similarly disposed of. 

244. The glandular structures of the intestines, especially those in 
and near the caecum, evidently bear a part in freeing the system from 
noxious matters, though, from the nature of the case, it is not possible 

ra their precise function. Their inflamed and diseased condition 
in typhoid fever, and under the fatal operation of such poisons as 

, mercury, and antimony, coupled with the fact that, in poison- 
ing by the last-named substance, they have been found to contain it 
quantity, justify us in classing these intestinal glands among 
the most important of the excreting organs. 



ELIMINATION OF WATER AND CARBON. 53 

245. By the lungs, skin, kidneys, liver, and bowels, the blood is 
freed from useless or hurtful matters. The excretions of these organs 
have been examined separately ; but it will be useful to consider them 
collectively, in order to show what share each bears in removing effete 
matters from the blood. 

246. An average of fourteen experiments made by Dalton on his 
own person, on successive days in the month of March, gave the follow- 
ing results, the urine and fasces being ascertained by weight, and the 
secretions of the skin and lungs by calculation. 

The ingesta weighed 91 ounces. The egesta were as follows : — 

Urine 48^ oz. ; exhalation from the lungs and skin 37J oz. (30f oz. 
by the lungs, and 6§ oz. by the skin) ; faeces 5 oz. : or, more than 
half by the kidneys ; a third by the lungs; a thirteenth by the skin ; 
and an eighteenth by the bowels. 

247. The bulk of these excretions, and consequently of the food and 
drink by which they are supplied, consists of water. Of the 91 ounces, 
no less than 76 consisted of water, which was contained in the several 
excretions in the following proportions : — 

Urine 45J oz. ; lungs 20J oz. ; skin 6J oz. ; fasces 3f oz. Total, 
76 oz., or, about five-eighths by the kidneys ; a fourth by the lungs ; a 
twelfth by the skin ; and a twentieth by the bowels. 

248. The separation of water is evidently an important use of these 
excretions, and it is easy to understand how one of these organs may 
become vicarious of another in this respect. Thus, when the exhalation 
from the skin is increased by exercise or by any other cause, the urine 
is diminished ; when, on the other hand^ as in diabetes, the flow of 
urine is increased, the skin becomes dry and harsh. The functions of 
the lungs and skin are also closely connected. When, during exercise, 
the skin is moist, the respiration is free ; but if, the skin being dry, the 
circulation is at the same time excited, the respiration is oppressed ; but 
the moment moisture breaks out on the skin, the lungs are relieved as 
by a charm, and respiration becomes natural and easy. The pedestrian 
will recognise the truth of this statement, it is the rationale of the 
" second wind " of those who take strong exercise. 

249. The quantity of water removed by the bowels being compara- 
tively small, has little effect on the other secretions ; but if increased by 
the operation of a purgative, the urine is diminished, and in violent 
diarrhoea, and in cholera especially, is often entirely suppressed. The 
exhalation from the lungs is also probably affected by the quantity of 
the secretions poured out by the other organs. 

250. Next to the water thus removed from the system, the most 
abundant material is carbon. It is eliminated by the different organs 
in the following proportions : — 

Lungs 10 J oz. ; skin J.oz. ; urine J oz. ; fasces J oz. Total, 11 j oz. 
Hence the blood is purified of its carbon by the lungs, kidneys, skin, and 



54: PHYSIOLOGY AND GENERAL PATHOLOGY. 

liver. Of these the lungs excrete so much the larger proportion, that 
no single organ, nor all jointly, can supply their place when their 
functions are much embarrassed. Some of the carbon contained in the 
faeces is furnished by the bile. The rest has never formed part of the 
circulating fluid. 

251. The lungs and skin excrete carbon with oxygen, as carbonic acid ; 
the kidney, with nitrogen and oxygen, and a small proportion of hydro- 
gen, as urea and uric acid ; and the liver, with oxygen, hydrogen, and 
comparatively little nitrogen, as cholic and glycocholic acids. As the 
carbon is similarly combined in the secretions of the lungs and skin, it 
is easily seen how the functions of the skin may become vicarious of 
those of the lungs. The relief afforded to the lungs during exercise by 
free perspiration probably arises in part from the excretion of carbonic 
acid ; and the same may be said of the colliquative sweats in phthisis. 

252. The close relation existing between the functions of the liver and 
lungs is proved by the frequent coexistence of diseases of those organs : 
tnat the one may be vicarious of the other is shown by the large size 
of the liver in the foetus. 

253. The essential constituent of the urine (urea) contains carbon in 
considerable quantity. It is directly derived by oxidation from uric 
acid, which contains twice the quantity of carbon, and is regarded as a 
product intermediate between the effete nervo-muscular tissues on the 
one hand, and urea on the other. Disordered function of the lungs or 
skin leads, therefore, to the accumulation of uric acid in the system. 

254. Nitrogen is at one time absorbed, at another exhaled, by the 
lungs, also by the skin in variable, but probably not in large quantity ; 
but it is nearly absent from the bile. The appropriate organ for its 
removal from the system is the kidney. In what degree other excre- 
tions may be vicarious of the kidney in this respect is not yet known. 
In uraemia the stomach attempts the elimination of urea. 

255. The secretions of the skin, kidneys, and liver abound in salts; 
one of these organs may, therefore, to a certain extent, become vica- 
rious of another in their removal from the system. Certain saline sub- 
stances are accumulated in large quantity in diseased organs at the 
expense of some secretion of which they form a normal constituent. 
Thus common salt, found in excess in the sputa from hepatized lungs, 
but absent from the urine, is restored to the urine on the subsidence of 
the disease, as has been shown by Dr. Beale. 

25G. In the similarity of the matters excreted by the several organs, 
we recognise a provision for maintaining the normal constitution of the 
blood under the less severe functional disorders ; while the efforts made 
by one organ to supply the place of another, probably account for some 
of the more familiar symptoms of disease. When these efforts are 
unavailing, the constitution of the blood becomes seriously altered, to 
the imminent danger of the patient. 






ESGESTA AND EGESTA. 

257. The following table presents at one view the results of Daltc 
experiments ; the last three lines being rude approximations : — 



Egesta 
Water . . 

Solid residue. 



Pulmonary Cutaneous 
Exhalation. Exhalation. 
30f oz. . . 6|oz. . . 
, 20£oz. . . 6£oz. . . 

lOJoz. , 



Urine. 
48^oz. 
45Aoz. 



Fasces. 



Uoz. 



Consisting of substances containing — 
Carbon . . . lOJoz. . . ^oz. . . ^oz. 
Nitrogen and other gaseous elements of urea 

and uric acid, exclusive of carbon . . ljoz. 

Salts, &c 1 oz. 

Residue of undigested matters 



Total. 
91 oz. 
76|oz. 

14|oz. 

lljoz. 

ljoz. 

1 oz. 

foz. 



258. In the foregoing statement and tabular summary no notice is 
taken of the large quantity of oxygen received through the lungs. 
This gas, as essential to the support of the frame as food itself, bv 
uniting with the effete textures, gives rise to compounds which cannot 
support life, and these being absorbed into the current of the circula- 
tion, seek their exit from the body through the excreting organs. If 
w^e suppose the weight of the body to remain unchanged, the oxygen 
introduced by the act of respiration, added to the food consumed, must 
equal in weight the matters rejected by the excreting organs. The 
part borne by each organ in this work of elimination is shown in the 
following table, which embodies the figures of tw T o tables given by 
Vierordt in his ' Grundriss der Physiologie,' p. 192. 3952 grammes 
of food and drink are resolved into their elements, and traced, so to 
speak, into the excretions through which they pass from the body. 









Excreted by 




Received as Food. 














Lungs 


Skin 


Kidneys 


Bowels 


1 


Water in food and drink . 


2,818 


330 


660 


1,700 


128 




Oxvgen (from air 744, 














from food 38) . 


782 


651 


7 


11 


12 


101 


Hvdrogen from food . 


19 






3 


3 


13 


Carbon „ . . 


282 


249 


3 


10 


20 




Nitrogen „ 


19 






16 


3 




Salts ,, . . 


32 






26 


6 


•• 




3,952 


1,230 


670 


1,766 


172 


114 



With the exception of 101 parts of oxygen and 13 of hydrogen, 
supposed to unite as water, the watery, gaseous, and saline elements of 
the food are here traced to the organs by which they leave the body. 
It is worthy of remark that in the experiments from which these 



56 PHYSIOLOGY AND GENERAL PATHOLOGY. 

figures are deduced, the oxygen received in respiration is little less 
than a fifth part by weight of all the solid and liquid matters taken as 
food, and very nearly twice as great as the oxygen, carbon, hydrogen, 
nitrogen, and saline matters contained in all that part of the food that 
is not water. 

2. PHYSIOLOGY AND GENERAL PATHOLOGY OF THE CIRCULATING 

SYSTEM. 

Having now examined the function of digestion ; the blood, and its 
constituents ; the secretions destined to further uses ; and the excre- 
tions by which the blood is freed from useless or hurtful matters ; — it- 
remains to consider the mechanical arrangements by which the blood 
is renewed, purified, and distributed through the frame: in other words, 
to examine the functions of absorption, secretion, nutrition, and circu- 
lation. This will be done in the following order : — the action of the 
heart ; the motion of the blood in the arteries ; the functions of the 
capillaries, of the veins, and of the absorbents. 

259. The Circulation. — The heart is the centre of two incomplete 
circulations ; one through the lungs, beginning at the right ventricle, 
and ending at the left auricle ; the other through the body, commenc- 
ing at the left ventricle, and ending at the right auricle ; the two 
together forming a complete circulation, an uninterrupted stream of 
blood. A third circuit consists of the coronary arteries springing from 
the commencement of the aorta, and the coronary vein opening into the 
right auricle. 

260. These three incomplete circulations consist of vessels, all of 
which are always, and in all states of the living body, full of blood, 
though more or less distended as it is increased or lessened in quantity. 

261. The vessels in question consist of an arterial trunk split into 
numerous small branches, of a venous trunk formed by the union of 
equally numerous small veins, and of capillary vessels uniting the two, 
and this — arteries dividing into small branches, and corresponding 
small veins uniting to form venous trunks — is, with the exception of 
the vena porta;-, and the minute vascular system of the kidney, the 
mechanism of the circulation throughout the body. 

262. A general view of the circulation, including the portal system, 
is given in Fig. 1, in which a d represents the circulation through the 
body, b c the circulation through the lungs, e e the exceptional portal 
svstem, dxAgg the lymphatic and lacteal system. The darker parts 
of the plan, on the left of the diagram, represent the venous system, 
and the lighter, to the right, the arterial system. The arrows indicate 
the direction of the stream of blood. The circulation through the heart 
is apparent without the use of letters. 

263. TJte Heart's Action. — The heart is the source, and chief cause, 
of the circulation through the blood-vessels. The ventricles, expelling 
their contents with more or less frequency and force, in different per- 



SCHEME OF THE CIRCULATION. 0( 

sons, and in the same person at different ages and at different times, 
send out at each contraction the blood received into the auricles from 
the large venous trunks. 

Fig. 1. 




264. The average number ot contractions in a 'minute maybe set 
down at 70 for an adult male, and 80 for an adult female. The quan- 



58 PHYSIOLOGY ASTD GENERAL PATHOLOGY. 

tity of blood forced into the aorta at each beat of the heart in a healthy 
adult has been variously estimated at from two to five or six ounces : 
and the total quantity contained in the body at about twenty pounds 
(§ 190). Assuming two ounces to be expelled at each contraction, 
twenty pounds to be the weight of the whole mass of blood, and the 
pulse to beat seventy times in a minute, and further assuming the 
whole of the blood to be always in the current of the circulation, it is 
obvious that any given portion of it could not complete the circuit of 
the body in less than two minutes forty seconds. Al tiller, however, 
estimated the time required at from one to two minutes, and Volkmann 
at 34-J seconds in an infant, and 65f seconds in an adult male. But 
Hering's experiments on the horse prove that the circulation may be 
completed in twenty-five or thirty seconds ; while more accurate expe- 
riments of Blake's give from twelve to twenty seconds. For the dog, 
Mr. Blake's experiments give so short a period as nine seconds ; and 
he showed that, in the same animal, a poison passes from the jugular 
vein to the lungs in four seconds ; from the jugular vein to the coronary 
arteries of the heart in seven seconds ; from the jugular vein to the 
carotid artery in from five to seven seconds ; and from the aorta to 
the capillaries in four seconds. Bernard has also shown that when a 
solution of sulphuretted hydrogen is introduced into the jugular vein 
of a dog, the gas begins to be eliminated from the lungs in three 
seconds, and when introduced into the femoral vein in seven seconds. 

The estimated quantity of the blood must, therefore, be too high, 
and that expelled at each beat of the heart too low ; or, what is perhaps 
as probable, the whole of the blood is not constantly in the current of 
the circulation, but remains for a time in the capillary vessels, subserv- 
ing the functions of secretion and reparation. The observed difference 
between the velocity of that part of the stream of blood which is in 
contact with the sides of the vessels, and of that which occupies their 
central axis, is also another element in the explanation of the difference 
between calculation and experiment. 

265. The force with which the blood is expelled by the left ventricle 
has been estimated at somewhat more than four pounds. 

266. T'ne Arteries. — The blood sent out by the heart is distributed 
to every part of the body by the arteries. The larger arterial trunks 
are highly-elastic tubes, destitute of muscular fibre, admitting of expan- 
sion, both transverse and longitudinal, and able to adapt themselves to 
the volume of their contents. With each contraction of the heart they 
are expanded and slightly curved; and Poiseuille has shown that they 
undergo an increase of size, amounting, in the carotid artery of the 
horse, to J 3 rd of its capacity. 

The larger arteries, by yielding to the impulse of the blood and re- 
acting upon it, cause a delay in its motion which would not occur in 
rigid tubes ; hence the pulse is somewhat later in the arteries remote 
from the heart than in those near it. This elasticity also equalizes 
the motion of the blood in the smaller vessels, and c:\uses it to flow in 



THE CAPILL ABIES. 



59 



an even stream. It aVo accounts for their empty state after death, 
their contents being forced into the veins. In old age this property is 
lost through degeneracy or ossification. 

267. The dilatation of the arteries can only be made apparent by the 
use of ingenious instruments ; but the large arteries may be seen to 
throb. This is owing to the longitudinal extension of the vessel. It 
is stretched and curved outwards by the forcible injection of blood ; 
and if the finger be applied to it with a tolerably firm pressure, this 
effort, at change of place is felt. But this is not all ; for the pressure 
of the finger is resisted by the blood forced into the artery : and this 
resistance is also felt. These two things together, the change of place, 
and resistance to pressure, constitute the Pulse, which will be more 
minutely examined in the next chapter. 

268. The smaller arteries which communicate directly with the small 
veins, or from which the capillaries spring, have two muscular coats, 
the inner longitudinal, the outer circular. In cases of obstructed capil- 
lary circulation these muscular fibres have been found hypertrophied ; 
and there is reason to believe that this condition, first demonstrated by 
Dr. George Johnson in the case of the minute arteries of the kidney, 
extends to the small arteries of every organ of the body, and plays an 
important part in regulating the local supplies of blood. The arteries 
intermediate between the large trunks and their smaller branches, have 
more or less muscular fibre as they approach to the one or the other 
class of vessels. 

269. The capillaries are vessels of extreme minuteness, consisting ot 
a single membranous coat, through which the portion of the blood des- 
tined for secretion or nutrition finds its 
way. They form a network, between the 
meshes of which the proper substance of each 
organ lies, or they are so disposed as to adapt 
themselves to the form and arrangement 
of the several tissues ; and they establish 
a communication between the last divisions 
of the arteries, and the first of the veins, 
The small arteries which do not lose them- 
selves in veins have no other termination, 
and the veins no other origin ; and there are 
no vessels terminating by open mouths. 
This continuity of the arterial and venous 
system through the intervention of the 
capillaries is shown in the annexed engrav- 
ing of the villi of the small intestine (Fig. 2), 
in which the shaded vessels represent the veins, 
the arteries. 

270. The motion of the blood in the capillaries is mainly due to the 
heart's action ; its constant and equable rlow to the elasticity of the 
arterial trunks ; and some modifications, at present little understood, 



Fig. 2. 




and those in outline 



60 



PHYSIOLOGY AND GENERAL PATHOLOGY. 



to the muscular contractions of the smaller arteries, and to the processes 
of secretion and nutrition going on in the parts to which the vessels are 
distributed. The motion of the blood is slow in the capillaries, owing 
to the resistance offered by the coats — a resistance calculated at from 
two-thirds to three-fifths of the force of the heart. 

271. In health, the capillaries subserve the important function of 
nutrition by allowing the ready exsudation through their thin mem- 
branous wall of the materials which the several tissues require for their 
growth and repair ; and in disease they play an important part in the 
changes known as inflammation, irritation, and congestion, 

272. The minute arteries and capillary vessels are subject to changes 
in health, which enable us to understand disease. Shame brings a blush 
to the cheek ; fear blanches it. Warmth and exercise redden the skin ; 
cold and continued rest deprive it of colour. Now, the blush of shame, 
the redness caused by heat, the glow of exercise, and the pallor produced 
by fear, by cold, or by continued rest, depend on changes in the circu- 
lation through the small arteries and capillary vessels. 

273. There are three distinct ways in which redness of the surface, 
due to changes in the small vessels, maybe brought about : — the circu- 
lation may be quickened, 

Fig. 3. so that more red particles 

traverse the vessels in the 
same time ; or that por- 
tion of the calibre of the 
vessels which is nearest to 
their coats, and which in 
tranquil states of circula- 
tion transmits a colourless 
fluid, may admit the red 
particles ; or the size of 

/"t— ■^o'«riBIW is fi^^\---/'^ ^ ie vesse ^ s ma y ^ e m ~ 

creased. These statements 
are fully borne out by 
microscopic examination 
of the circulation in the 
frog's foot (Fig. 3). 

The velocity of the cir- 
culation is seen to increase, 
the outer portion, a a, of 
the calibre of the vessels 
to admit red particles, c d, 
and the size of the vessels, b b, to increase or decrease. 

274. In the examples just adduced we have three distinct causes of 
determination of blood to the skin : in the first an emotion of* the mind ; 
in the second, a local application to the vessels; in the third, the in- 
creased action of the heart. From the first example it appears that the 







THEOEY OF INFLAMMATION. 61 

state of the small vessels may be changed without increased action of 
the heart, for if the enlargement were due to that cause, the blush 
would not be confined to the cheek ; from the second, that local appli- 
cations will affect them in the same way ; and from the third, that the 
same result may follow from the stronger and more frequent contrac- 
tion of the heart itself. The cases in which pallor of the skin occurs are 
equally instructive, proving as they do the local effect of emotion in 
contracting the small vessels, the equally local effect of cold, and the 
remote effect of a quiet action of the heart. 

275. In the effects of emotion and of stimulating local applications 
we have examples of the small vessels dilating without any force from 
behind, and in the act of blushing, proof of a relaxation of the muscular 
coats of the small arteries, due to a nervous influence. 

270. As the capillaries consist of a single membranous coat, without 
muscular fibres, it is probable that they are passive in the local changes 
that occur in the circulation of the blood, and that the rate of the cir- 
culation through them is determined by the state of the small arteries 
on the one hand, and the greater or less vigour of the processes of secre- 
tion and nutrition on the other. 

277. It appears, then, that, in one instance at least, the enlarge- 
ment of the minute arteries is only to be accounted tor by a diminution 
or suspension of their contractility. Now, this same enlargement of 
the small arteries occurs in inflammation. Is it due to the same cause? 
A grain of sand gets into the eye, and in a short time the vessels of 
the conjunctiva become filled with red blood, and enlarged, obviously 
without any increased action of the heart, for the other eye, equally 
affected by the general circulation, is not inflamed. Again, the imme- 
diate effect of ice applied to the finger is to contract the vessels ; but 
no sooner is it removed, than the pale skin resumes its colour and be- 
comes even redder than the surrounding skin. This change, too, is 
strictly local, and independent of the heart's action. The same contrac- 
tion of the small arteries, followed after a variable interval by dilatation, 
has been shown, by experiments under the microscope, to follow the 
application of mechanical and chemical irritants. So that it may be 
stated as a general fact, that the agents which excite inflammation first 
cause contraction of the small vessels ; and that this contraction is 
followed by dilatation. 

278. These actions take place in obedience to a general law, that 
stimuli applied to any part of the body, acting through its nerves, 
develope the special functions of that part for a time, but that the nerv- 
ous force suffers an exhaustion proportionate to its intensity and dura- 
tion, and brings about a condition the very reverse of that which existed 
when the stimuli were first applied. In the case now under considera- 
tion the stimulus first deveiopes the proper function of the small 
arteries (their contractility), exhaustion ensues, that function is para- 
lysed, the vessels expand, and yield to the impulse of the blood. 



62 



PHYSIOLOGY AND GENERAL PATHOLOGY. 



279. During this first period of contraction the flow of the blood is 
retarded ; but when the vessels become dilated, the circulation is acce- 
lerated, to be again retarded after 
Fig. 4. an interval of time. The small 

vessels, in becoming dilated, are 
also stretched and twisted, and 
here and there even become vari- 
cose, as is shown in the annexed 
engraving from Valentin, after 
Harting (Fig. 4). In consequence 
of this inciease of size, the vessels 
admit a larger number of red par- 
ticles; and those that previously 
conveyed only colourless blood, 
now become carriers of red blood. 







280. The changes that occur in 
an inflamed part are not long con- 
fined to the small vessels. The 
larger arteries and veins suffer the 
same dilatation ; and if the inflammation prove severe and extensive, the 
arterial trunks themselves participate ; and thus large portions of the body 
— a hand, a foot, a limb, or an internal organ — become so many congeries 
of enlarged vessels containing more blood than those of the corre- 
sponding part of the body. An inflamed hand, for instance, contains 
much more blood than the sound one; its radial artery is evidently 
enlarged, through loss of contractility and increased action of the heart ; 
and if a vein of that side be opened, it will pour forth much more blood 
than the vein of the opposite side. 

281. Through the increased action of the heart, which occurs in all 
acute inflammations, blood is sent in greater quantity to every part 
of the frame, and gives rise to symptomatic fever, converted, if the 
nervous system suffer much, to the state known as irritation, constitu- 
tional irritation, or irritative fever ; if the patient has been intemperate, 
the loss of his accustomed stimulus, and the increased flow of blood to 
the brain, may give rise to delirium tremens ; and, should the power 
of the constitution have been previously exhausted, the fever may 
assume the typhous type in place of the milder form it assumes in the 
sti ong and robust. 

282. It appeal's, then, that in acute inflammation both the heart 
and the small arteries are ultimately involved, the one sending forth 
more blood, the other receiving more. The heart's action, which is 

\r contraction, is increased ; the <u;ti<m of the small arteries, 
which is also muscular contraction, is diminished. So that there is no 
such thing as the increased action of the arteries, in the sense in which 

ra was formerly used: that which was called increased action, 
i-, in fact, diminished action. 

283. This account of the state of the vascular system, and of t\\e 



INFLAMMATION — NUTRITION. 63 

circulation generally, in inflammation, though sufficient for practical 
purposes, must not be taken to be a complete theory of inflammation. 
We have yet to take into account the organic tissues, to the functions 
of which the whole vascular system is subservient — the arteries and 
veins as carriers of the blood to and from them, and the capillaries as 
the intermediate connecting tubes through the membranous walls of 
which the tissues attract the materials of their growth and repair, and 
the fluid solvent of such portions of them as have served their purpose 
in the economy, and become effete. 

284. The secreting cells, which constitute the bulk of these tissues, 
play an important part in the production of inflammation. When it 
originates in increased action of the heart, the function of secretion in 
the cells is deranged by the turgescence of the vessels. The increased 
quantity of blood imposes on them more work than they are able to 
perform. Hence, the elements of the secretion accumulate in the 
blood, while the turgescence of the vessels is increased and perpetuated. 
On the other hand, when the first link in the chain of causes is an 
accumulation in the blood of the elements of an important secretion, 
say of the bile or urine, or the introduction of a poison, such as anti- 
mony, arsenic, or mercury, the second link is the rapid destruction of 
the secreting colls, the third, the arrest of the circulation in the capil- 
laries, and the last link of the local chain, the dilatation of the small 
arteries. An increased action of the heart is all that is needed to com- 
plete the idea of inflammation as it commonly presents itself. 

285. An excellent illustration of the share the secreting cells have in 
bringing about these phenomena is afforded by inflammation of the 
kidney. The first link in the chain of causes is a rapid desquamation 
of the epithelial cells lining the urinary tubes ; the detached cells clog 
the tubes ; the blood in the capillaries is arrested, and blood or serum 
is extravasated from the Malpighian tufts. 

286. The processes of nutrition and inflammation are, in fact, strictly 
analogous. In healthy nutrition the cells of the tissues attract from the 
blood, through the walls of the capillaries, the materials of growth and 
repair; while the liquor sanguinis, from which these materials have 
been abstracted, having dissolved the debris of the effete textures, is 
restored to the circulation by the absorbents and veins. In adults, 
under ordinary circumstances, the formation of new exactly counter- 
balances the destruction of old tissue ; but during the period of growth, 
and in certain parts of the system, as the womb and breasts, to meet 
an occasional demand, nutrition is more active than the work of deduc- 
tion. The same thing happens in some subacute inflammations which 
terminate in hypertrophy. In healthy inflammation, too, the increased 
attraction of the tissues draws from the capillaries liquor sanguinis, or 
coagulable lymph rich in fibrine, and capable of developing cells by 
which the destructive effects of inflammation are repaired, or the 
tissues increase in bulk and firmness. 

287. The enlargement of the small vessels in inflammation, then, is 



64 PHYSIOLOGY AND GENERAL PATHOLOGY. 

quickly followed by effusion. When the skin is inflamed, as by a burn, 
serum is thrown out from the surface under the cuticle, and a blister 
rises : when a mucous or serous membrane is inflamed, fluid exsudes 
from its surface : when the cellular membrane is attacked, the fluid is 
poured into its cells. This effusion varies with the constitution 'and 
state of system, the condition of the part, and the intensity and nature 
of the inflammation ; and may present every variety between a lymph 
abounding in fibrine, and a lymph rich in granules or corpuscles. 

288. The lowest degree of inflammation merely increases the natural 
secretion of the part attacked — of serum, in the case of serous mem- 
brane — of mucus, when a mucous surface is inflamed. A higher 
degree of inflammation causes the effusion of coagulable lymph (the 
fibrine of the liquor sanguinis) or of pus. The increased natural secre- 
tion of the serous membranes is dropsy, or, when of limited extent, 
oedema ; that of the mucous membranes, flux. Both these membranes, 
also, when the inflammation is more intense, pour out fibrine or pus. 
It is in this way that the inflamed surfaces of the pleura or peri- 
toneum become glued together, and the effused matter, becoming 
organized, forms permanent adhesions. The mucous membranes, too, 
when highly inflamed, pour out coagulable lymph of such tenacity as 
to assume the shape of the tubes which they line, and even to be mis- 
taken for the detached lining membrane itself. This occurs in the 
larynx, in diptheria and croup ; in the bronchial tubes, in a peculiar 
form of bronchitis ; in the intestines, in dysentery ; in the kidneys, in 
inflammatory affections of those organs. Of purulent secretion from 
serous membranes, empyema is an example ; and of the formation of 
pus by mucous surfaces, purulent ophthalmia. 

289. When the small vessels return to their natural size, and any 
fluid that may have been poured into the surrounding textures is 
absorbed, the inflammation is said to terminate by resolution ; when 
blood is thrown out, by haemorrhage ; when serum, by effusion ; when 
fibrine or coagulable lymph is formed and organized, by adhesion ; 
when pus is effused, by suppuration ; when the part dies, by gangrene. 
Inflammation of mucous surfaces, or of exposed portions of cellular 
membrane, accompanied by the effusion of pus, and the more or less 
rapid removal of the part affected, constitutes ulceration ; and a similar 
process in the substance of organs is known as ramollissement, or 
softening. 

290. The generic term inflammation is often qualified by other words 
indicative of its character. Thus we have ccdematous inflammation, or 
inflammation terminating in, or accompanied by, oedema ; adhesive, or 
inflammation terminating in adhesion; suppurative, or inflammation 
issuing in su gangrenous, or inflammation ending in gan- 
grene. The terms acute, and chronic, healthy and unhealthy, common 
and specipc, phlegmonous and erysipelatous, are also used to designate 
varieties of inflammation. 

291. When inflammation attacks the cellular membrane, whether in 



SUPPURATION. 65 

the skin or in the substance of internal organs, it takes different courses 
according to its intensity. If slight, it terminates in resolution ; if 
more severe, effusion may take place ; if more severe still, suppuration : 
if still more intense, gangrene. If a portion of the cellular membrane 
die, or if blood, serum, or fibrine is poured out so abundantly as to 
distend and break down the tissue, pus is thrown out in small detached 
portions, which, by solution of the intervening parts, coalesce, so as to 
form one single collection of purulent matter, round which a wall of 
fibrine or coagulable lymph is built up, becomes organized, and consti- 
tutes a cyst or sac. This collection of pus in a cavity, bounded by a 
wall of effused and organized fibrine, is called an abscess — a term which, 
like the word inflammation, is qualified in practice by phrases indicative 
of its character or progress, such as the acute or phlegmonous, and the 
cfooniG abscess. 

292. Sometimes the constitution is not strong enough to build up 
and organize a wall of fibrine about the dead part, and then the pus 
finds its way into the surrounding cellular texture, and forms a diffused 
abscess, or the inflammation is peculiar, as in erysipelas, and suppura- 
tion takes place with little or no adhesion. 

293. In rare instances the pus which had been thrown out is 
absorbed, and the abscess is said to be dispersed : but in the majority 
of cases fresh pus is formed, the abscess increases in size, and presses on 
surrounding parts, some of which yield to the pressure, and then the 
abscess is said to point ; and if it is near the surface, the skin itself 
offers least resistance, is protruded, and stretched more and more, till it 
bursts. 

294. When the matter of an abscess is discharged, the cavity con- 
tracts, the fibrinous lining is cast off, and the walls become a suppu- 
rating surface, on which fresh fibrine is effused. Part of this fibrine 
becomes organized by vessels, which either form within it, and then 
connect themselves with those of surrounding parts, or gradually extend 
into it from those parts. These newly- organized portions of fibrine are 
arranged side by side as small rounded vascular points, called granula- 
tions. The fresh surface thus created secretes pus, which protects it 
from the air. When the granulations approach the surface, the pus 
hardens into a scab, which forms a still more efficient protection. In 
healthy persons the granulations are numerous, small, and florid, and 
coated with a creamy pus, known to the older surgical writers as 
laudable pus. Unhealthy granulations, on the other hand, are large, 
pale, and flabby, and discharge a thin flaky pus. The various appear- 
ances presented by the granulations, and the changes they undergo 
with alterations in the general health, form a subject of interesting and 
instructive study. 

295. When the tissues are divided, and the two edges of the wound 
thus formed are brought close together, and kept in contact, a speedy 
and perfect union may take place, and the wound is then said to 
have been healed by the first intention. But the part may not heal 



66 PHYSIOLOGY AXD GENERAL PATHOLOGY. 

in this simple way : the wound may gape, and an open sore or ulcer be 
formed, presenting the same granulations as the walls of an abscess that 
has burst. These, once completely organized, secrete fresh coagulable 
lymph, and this, in its turn, is moulded into new granulations ; and 
thus the ulcer is at length filled up to a level with the surrounding 
skin, and protected by a scab ; a small portion of new tissue is mean- 
while formed between the edges of the wound which gradually contract 
as the surface heals. Ultimately the scab falls off and exposes the 
new-formed tissue. The scar, or cicatrix, is at first red, but the 
colour gradually fades, and at length the scar is recognised by its 
whiteness. 

296. As a general rule, abscesses, whether in the integuments or in 
the solid viscera of the body, tend towards the surface ; but to this rule 
there are exceptions. If, for instance, an abscess form in such an organ 
as the liver, its firm close structure may offer more resistance than the 
loose texture of an adjoining intestine : the abscess presses upon its 
coats, and adhesive inflammation is set up between the two layers of 
serous membrane ; the peritoneum and the coats of the intestine are 
thus so glued together as to form one continuous texture through which 
the abscess, continually increasing, forces its way, till it bursts and 
discharges its contents. Sometimes the course of an abscess is more 
circuitous, as when an abscess of the liver finds its way through the 
diaphragm, and opens into the air-passages of the lungs. Sometimes, 
again, an abscess in a solid viscus discharges itself into the serous cavity 
which surrounds it. Abscess of the lung, opening into the sac of the 
pleura, is an example in point. 

297. As a general rule, the matter of an abscess takes the shortest 
course to its place of discharge; the most common exception being in 
the case of collections of matter formed beneath fasciae, by which they 
are bound down and diffused. 

298. Ulceration is very analogous to suppuration. Ulceration of 
the skin, for instance, begins with inflammation, and is followed by the 
effusion of serum or pus, known as a vesicle or pustule. This breaks, 
and leaves an uneven surface, covered with flakes of lymph, and 
moistened with pus, which may either heal in the way just described, 
or extend and enlarge by the destruction of the skin and subjacent 
textures. In ordinary cases the parts are removed gradually, and 
almost imperceptibly ; in others, with great rapidity, when the ulcer is 
called phagedenic; in others, again, the inflammation is so intense as 
to cause the death of considerable portions of the cellular membrane, in 
which ca^e it is called a sloughing ulcer. The most rapid destruction 
of parts with which we are acquainted has received the name of 
sloughing phagedena, or hospital gangrene. Ulcers are further de- 
signated as acute and chronic ; healthy and unhealthy, inflamed, indo- 
lent, and irritable ; coivjestvie, varicose, fistulous, rodent, &c. 

299. Gangrene is one of the terminations of inflammation ; and the 
death of a limited portion of the cellular or other texture is an occa- 



GAXGREXE — ERYSIPELAS. 67 

sional cause of abscess. The common boil is an example of a more 
extended death of the cellular tissue, and carbuncle of the worst form 
of boil. But gangrene may take place without the formation of an 
abscess. It may attack a limb, in consequence of the extreme languor 
of its circulation, and, beginning in the foot, extend upwards till it 
reaches a part where the circulation is active enough to allow of 
adhesive inflammation. Coagulable lymph is thrown out in a circle, 
dividing the sound from the dead parts ; granulations are formed, pus 
effused, and at length natural amputation of the dead member will be 
effected. Thus, through the different effects produced, and the different 
secretions poured out, in different degrees of inflammation, the body 
sets limits to its own diseases, and repairs the most severe injuries. 

300. Sometimes gangrene takes place without inflammation, as in a 
limb of which the arteries are ossified, or in cases of poisoning with 
ergot of rye : this is distinguished as dry gangrene. When gangrene, 
from extreme languor of the circulation in the lower extremeties, 
attacks aged persons, it is known as senile gangrene. 

301. The most common constitutional or predisposing cause of gan- 
grene is debility ; the most common exciting causes are severe mecha- 
nical injury, the action of violent irritants, pressure, and intense cold. 
The immediate or proximate causes are a deficient supply of arterial 
blood, impediments to the return of the venous blood, and injury or 
division of the nerves. The term mortification is commonly used as 
synonymous with gangrene ; and the word sphacelus, or sloujli, is 
generally employed to characterise a part not susceptible of being 
restored to life. 

302. A complete description of inflammation, its causes, its pheno- 
mena, its terminations, and the various modifications it undergoes in 
different states of health, in different constitutions, and in each texture 
of the body, would exceed the limits of this work; but there is one 
important species of inflammation known as erysipelatous, which must 
not be passed over. 

303. Erysipelatous inflammation is characterised by spreading over 
the skin or over the surface of membranes, by attacking different parts 
of the body, either simultaneously or by metastasis, by its contagious 
and infectious character, and by the lymph which is poured out being 
incapable of organisation. In its milder forms, as when it attacks the 
face, the disease scarcely extends beyond the skin itself, and is then 
called simple or cutaneous ; but in its more severe forms the cellular 
membrane is implicated, and the disease is known as phlegmonous 
erysipelas. 

304. Closely allied to erysipelas of the skin is that inflammation of 
the peritoneum which occurs in puerperal fever, associated with acute 
inflammation of the veins of the uterus and of other parts of the body, 
and followed by purulent deposits in the joints, and in the liver, lungs, 
and other viscera. The coexistence of erysipelas on the skin with puer- 



68 PHYSIOLOGY AND GENERAL PATHOLOGY. 

peral fever, of erysipelas on the infant and puerperal fever in the mother, 
and the occurrence of diffuse erysipelatous inflammation as the conse- 
quence of wounds received during the examination of the bodies of women 
who have died of the fever, fully establish this connection. 

305. Congestion is nearly allied to inflammation. It consists in a 
passive enlargement of the small vessels, without inflammatory symp- 
toms or other effusion than that which consists in an increase of the 
natural secretion of the part. This enlargement of the vessels is the 
effect of debility, and, as such, is apt to continue in parts in which the 
symptoms of acute inflammation have been subdued. It is common in 
the aged, and in persons exhausted by suffering. From its involving 
the veins rather than the arteries, it is often termed venous congestion. 
Pressure is a common cause of this state: hence congestion of the veins 
of the leg after long standing, of the vessels of the head from wearing 
a tight cravat, and in the lungs from hindrances to the respiration. 

306. Congestion of internal organs is a common occurrence, and 
plays an important part in the development of organic disease, and in 
the hsemorrhage and dropsy which so frequently accompany it. Some 
of the causes of visceral congestion, such as cold applied to the surface, 
a continued dry state of the skin in febrile disorders, and the plethora 
induced by a rich and stimulating diet, combined with insufficient exer- 
cise, are very simple and obvious. The continued action of these causes 
leads sooner or later to organic disease in some predisposed organ, such 
as the brain, the lungs, the liver, or the kidney. Hypertrophy of the 
left ventricle of the heart also gives rise first to congestion, and then 
to organic disease of all the internal organs. 

307. But besides this general internal congestion, leading to organic 
disease of some one of the congested organs, there are instances of con- 
gestion commencing in a single organ, and forming the first link in a 
chain of very interesting and instructive pathological changes, analo- 
gous to those already described as belonging to inflammation, §§ 268 
and 284. 

308. If we take the kidney as an example, the primary source of the 
congestion would seem to be, in all cases, either an impure condition of 
the blood (the impurity consisting in the excess of some element which 
should be eliminated by the kidney), or a process of desquamation 
strictly analogous to that of the skin in scarlatina. In either case, the 
first morbid change consists in desquamation, or separation of the 
secreting cells, which are rapidly thrown off in large numbers, so that 
the tubes become clogged, and further secretion impeded ; or the tubes 
become altogether denuded of their cells. This leads to congestion of 
the intertubular capillary vessels, extending backwards to the Malpighian 
capillaries, which, according to the degree of congestion, pour out blood 
0)- serum, or first blood, then serum. The blood thus poured out is 
partly discharged with the urine, and partly separated into its consti- 
tuent parts, the fibiine, and part of the colouring matter, coagulating 
in the tubes, and being voided in the form of cylindrical moulds. In 



! 



SECRETION AND NUTRITION. 69 

simple desquamation, these moulds have epithelium-scales adhering to 
their external surface, without oil globules : but in more severe forms 
of disease, especially where the secreting tubes are denuded of their cells, 
oil globules are found blended with the scales. The local congestion 
thus set up, if extensive or of long continuance, constitutes an obstacle 
to the movement of the blood, which ultimately affects the centre of 
the circulation, and leads first to over-action, and then to hypertrophy, 
of the left ventricle. After a time, this state of hypertrophy causes 
congestion of other internal organs, with the haemorrhages and the 
serous effusions that follow hypertrophy of the heart due primarily to 
other causes. (Dr. George Johnson.) 

309. Similar changes occur in asphyxia, as was shown by Dr. John 
Reid. The carbonic acid accumulating in too large a quantity to be 
eliminated by the secreting apparatus of the lungs, the capillary vessels 
become turgid, and death supervenes before inflammation has time to 
develope itself. 

310. Haemorrhage is a common consequence of congestion, when it 
is termed passive ; but it sometimes appears to flow immediately from 
the arteries, when it is termed active. Haemorrhage from the lungs is 
generally caused by rupture of an artery ; but in haemorrhage from the 
stomach and bowels, the blood seems to exsude through the coats of the 
vessels. Haemorrhage may also take place into the ducts of secreting 
organs, such as the liver or kidney. In scurvy and in putrid fevers the 
haemorrhage is due partly to weakness of the vessels, and partly to thin- 
ness of the blood. Haematemesis, melaena, and haemorrhoids, are examples 
of passive haemorrhage. The copious discharge of red blood from the 
bowels, traceable by the use of the speculum ani to a small spot in the 
mucous membrane of the intestine, is a good example of the active 
form. 

311. Nutrition and secretion. — These two processes are essentially 
the same ; for they consist in the development of simple cells endowed 
with independent vitality, and capable of assimilating from the blood 
their own peculiar fluids. 

312. The secreting organs assume various forms: but consist essen- 
tially of a basement membrane coated with epithelial cells, and covered 
externally with a network of blood-vessels. 

313. In nutrition each cell runs through its course of gradual deve- 
lopment and decay, and the products of its decomposition (the first in 
order being, as in all forms of decay, carbonic acid), are absorbed into 
the blood, and discharged by appropriate excreting organs. 

314. In secretion, too, the cells which form the essential secreting 
organ ripen by the absorption of materials constituting the secretion, 
and then break up and decay ; the mixed products being poured into 
tubes fitted for their reception and discharge. 

315. The fluids thus poured out by the secreting organs are known 



70 PHYSIOLOGY AND GENERAL PATHOLOGY. 

as excrementitious and recrementitious ; that is to say, they are expelled 
as hurtful, or retained to serve some useful purpose. 

316. To the class of excrementitious matters belong the urine, the 
sweat, the water and carbonic acid exhaled from the lungs, a small 
portion of the bile, the secretions of the several mucous membranes of 
the body, the menstrual discharge, and the hair, cuticle, and nails. Milk 
and semen, the one nutritive, the other reproductive, form a class by 
themselves. 

317. Of the recrementitious secretions some ^as those of the salivary 
glands, stomach, liver, and pancreas) subserve the process of digestion ; 
others (as the tears, aud the watery secretion of the Malpighian tufts 
of the kidney) cleanse the surface of the eye and the urinary tubes re- 
spectively; others again (as the sebaceous secretions of the skin, the 
mucus of the mucous membranes, and the aqueous secretion of the 
serous membranes) protect the parts which they moisten from injury, 
and facilitate their movements. 

318. Another secretion not destined to immediate expulsion from 
the body consists of the fat deposited in cells of the adipose tissue, giving 
roundness to the form, facilitating motion, protecting the external parts 
from cold, and serving as a store of nourishment. 

319. Of secreting organs in the membranous form the serous mem- 
branes (the pleura, peritonseum, arachnoid, and the synovial membranes 
of joints) are examples, as well as the mucous membranes (that lining 
the mouth and nostrils, the windpipe and lungs, the alimentary canal 
and the parts communicating with it, and that lining the urinary pas- 
sages and organs of generation). The skin is a compound organ, con- 
taining a variety of secreting glands. 

320. Glands, in the usual acceptation of the term, are of three kinds 
— 1, collections of blood vessels, as the spleen and placenta ; 2, similar 
congeries of lymphatic vessels (lymphatic glands) ; and 3, true secreting 
organs. These latter are of two kinds, the one secreting into cells a 
fluid to be again removed by absorption [e. g., the thymus and thyroid 
glands), the other furnished with ducts for the discharge of fluids, which 
either subserve other purposes in the economy, or are thrown off as 
useless. These organs all consist of an excretory duct, which, if we 
trace it backwards from its trunk, divides into branches, and these 
again into others of smaller size, until the smallest terminate in blind 
extremities of various shapes, called cells, follicles, acini, &c. On the 
outside of these minute terminations, the capillary blood-vessels ramify, 
and the appropriate secretion permeating their invisible pores, drops 
into the cell, follicle, or acinus, and thence flows into the duct. The 
unused blood is returned by appropriate veins. 

321. In the kidney, the secreting apparatus is more complicated, 
consisting of a tuft of vessels (the Malpighian body), which secrete water, 
and tubes lined with epithelium, which eliminate the solid constituents 
of the urine. The water serves to wash out these solid matters — an 



SECRETION — THE VEINS. 71 

operation assisted, in reptiles and fishes, and probably in mammalia also, 
by the cilia which line a portion of the tubes. 

322. Secretion, like nutrition, is subject to differences in degree and 
in kind. The natural secretion of a part is augmented by increased flow 
of blood, provided it be not excessive. Thus perspiration follows exer- 
cise, and diarrhoea ensues on slight inflammation of the mucous mem- 
brane of the bowels. Secretion may also be increased by debility of the 
small vessels, when the circulation is languid, as in the cold sweats 
following a faint, or preceding dissolution. These two causes of increased 
secretion — augmented flow of blood, and weakness of the vessels — com- 
bine to produce the night sweats of hectic fever. On the other hand, 
the natural secretion of a part is diminished when the supply of blood 
is either lessened or augmented, as is the case with the skin both in the 
cold and in the hot stage of fever. In this latter case, as soon as the 
fever subsides, and the quantity of blood sent to the skin falls to a cer- 
tain point, sweating begins. The nerves, too, have great effect on the 
secretions, as is seen in the flow of tears from grief, joy, or rage, and in 
the effects of fear or anxiety on the skin, kidneys, and bowels. Mental 
emotion, however, checks some secretions. Thus fear, which increases 
the secretion of the skin, checks that of the salivary glands. 

323. But the secretions vary in kind as well as in degree ; in other 
words, they are liable to morbid changes. Thus, the serous membranes, 
which in health secrete a watery mist or vapour, under a certain degree 
of inflammation pour out serum, and dropsy results ; under a higher 
degree liquor sanguinis is poured out ; under a different and perhaps 
higher degree, pus. The mucous membranes, according to the degree 
of inflammation, secrete a glairy fluid, tough mucus, pus, or fibrine, or 
all these secretions blended in different proportions, as may be observed 
in the course of a severe attack of catarrh. 

324. Serious consequences result from the suppression of secretions, 
or from the non-elimination of some of their important constituents. 
Jaundice is an example of the suppression of an entire secretion. The 
non-elimination of urea, or of its combinations, by the kidneys, is an 
example of the suppression of an important constituent, followed in 
slight cases by erythematous swellings and boils ; in more severe ones, 
by gout and rheumatism ; in extreme cases, by fatal coma. 

325. What has been said of the similarity of structure in. the several 
secreting organs will prepare us to view, without much surprise, the 
assumption by one secreting organ of the functions belonging to another. 
This is termed the metastasis of secretions. Familiar examples of this 
phenomena are, the secretion of urine, or of a fluid nearly resembling- 
it, by the skin and several of the mucous surfaces ; of bile, by almost 
all the secreting organs, as in jaundice ; of milk, by the skin and lungs ; 
and of the menstrual flux, by the vessels of the no.^e, lungs, and stomach, 
and from the surface of ulcers. 

326. The Veins. — The veins are larger than the arteries, and have no 



(L PHYSIOLOGY AND GENERAL PATHOLOGY. 

elastic coat. The larger veins of the extremities also differ from the 
arteries in being provided with valves to prevent regurgitation, and 
give support to the blood which they contain. 

327. The venous circulation is effected mainly by the impulse of the 
heart continued through the capillaries ; but it is assisted by the con- 
traction of the muscles of the extremities pressing the blood towards 
the heart. The movement of blood in the great veins near the heart 
is further accelerated by the act of inspiration, and partly, as some 
suppose, by the suction of the heart itself. 

328. At each inspiration the chest is enlarged by the descent of the 
diaphragm, and the elevation and tilting outwards of the ribs. This 
tends to produce a vacuum, which is prevented by the entrance of air, 
of blood, or of both. That the motion of the blood in the large veins 
is thus accelerated is shown by experiments, and by the phenomena 
attending the admission of air into wounds in the larger venous trunks. 
It has also been shown experimentally that at each systole of the heart a 
tendency to a vacuum exists in the pericardium, counteracted by the 
blood of the large veins distending the auricles. 

329. The assistance given to the venous circulation by inspiration is 
somewhat counteracted during expiration, when the pressure on the 
contents of the chest causes regurgitation of blood into the larger veins. 
As, however, the effect of inspiration is greater than that of expiration, 
there is a balance in favour of the circulation. 

330. When the right auriculo-ventricular valve allows of regurgita- 
tion, the blood flows back into the descending cava and jugular vein, 
causing a venous pulse. 

331. Poisonous substances introduced into wounds soon find their 
way into the veins. This proves either that the veins themselves 
absorb, or that the capillaries which terminate in them possess this 
power. It is through this absorption into the circulation that poisons 
act ; hence the efficacy of ligatures applied above wounds, of the 
abstraction of the blood below the ligature, and of the application of 
cupping-glasses, which answer the double purpose of ligatures and 
evacuators. 

332. Absorption. — This term is applied to the act of taking up into 
the circulation both fluid and solid matters, the latter being distin- 
guished as instertitial absorption. The capillaries and veins both act as 
absorbents ; but the lacteals and the absorbents, properly so called, are 
also provided, the one for the removal of the chyle from the intestines, 
the other for the removal of lymph from every part of the body. 

333. Absorption is certainly effected in more ways and by more 
means than one. Living and dead tissues allow the passage of fluid and 
gaseous matters through them. This is called imbibition. If two 
gases are in contact with the moist surfaces of a bladder, one within 



ABSOEPTION. 73 

and the other without, both will permeate the bladder till they are 
equally mixed. A gas, likewise, will pass through a moist bladder to 
mix with a fluid within it. This takes place in the lungs. Again, if 
a vessel be filled with water, and a moist bladder be tied over its 
mouth, so that the fluid is in contact with the bladder, and a salt be 
strewed over its surface, it will be dissolved by the water which per- 
meates its pores. If a tube filled with a solution of salt or sugar, and 
closed by a bladder, be placed in water, the water permeates the bladder, 
mixes with the solution, and rises in the tube. At the same time part of 
the fluid contained in the tube traverses the bladder in an opposite direction, 
and this interchange takes place till the fluids on both sides have become 
homogeneous. If the arrangement be reversed, so that the denser liquid 
is outside the bladder, and the rarer liquid in the tube, the liquid in the 
tube passes through the bladder, and gradually sinks to a lower level. 
These phenomena constitute the "endosmose" and "exosmose" of 
Dutrochet. Lastly, if a vessel made of vegetable parchment, or 
other permeable material, filled with a liquid consisting of animal, 
vegetable, or mixed matters holding some salt or metallic oxide in 
solution, be floated on the surface of distilled water, the salt or metallic 
oxide will traverse the membrane and dose itself in the water, the 
thick, gummy matters remaining behind. To this process, devised by 
Graham, the term dialysis has been applied. These processes of 
imbibition, endosmose and exosmose, and dialysis, are believed to bear 
their parts in the work of absorption. 

334. Matters in solution pass into the capillaries, and thence into 
the veins by the process of " endosmose," which goes on the more 
rapidly as the denser fluid (the blood) is no sooner diluted than it gives 
place to a fresh portion, and thus endosmose takes place more com- 
pletely, and goes on more constantly, than in fluids at rest. 

335. This process of absorption is very rapid. In a part free from 
epidermis it is almost instantaneous ; and minute portions of fluid, or 
of substances held in solution, may be absorbed, and distributed through 
the body in from less than half a minute to two minutes. In this way 
the rapid action of the more energetic poisons is explained ; and it is 
only in rare instances, if in any, that a different explanation is needed. 

336. The rapidity with which absorption takes place is shown by 
the passage of certain salts from the stomach to the kidney. In one 
experiment made by Westrumb, prussiate of potash was detected in the 
urine after two minutes ; and in the history appended to a cast of 
the Epispadian Arburg, in the museum of King's College, it is stated 
that fluids may be seen trickling from the ureters into the bladder in 
from two to three minutes after they have been swallowed. 

337. Several agents affect the rapidity with which imbibition and 
absorption take place. Of these galvanism is the chief. Thus Fodere' 
showed that when a solution of sulphate of iron is poured into the 
peritonaeum, and one of prussiate of potash into the pleura, five or six 
minutes usually elapse before the two combine, but that this happens 



f4 PHYSIOLOGY AND GENEKAL PATHOLOGY. 

instantaneously when a slight galvanic current is passed through the 
diaphragm. Absorption is also promoted by friction. Again, dis- 
tension of the vessels retards absorption, while depletion accelerates it. 
Hence the use of venisection in dropsy. Absorption also takes place 
slowly in parts covered by dense membrane. Hence the absorbing 
power of the skin is much increased by removing the cuticle. Absorp- 
tion takes place readily from the subcutaneous cellular tissue. 

338. All these means of promoting absorption are used in the practice 
of medicine — galvanism, especially in the case of effusions into joints ; 
depletion in dropsies of the skin and serous cavities ; abrasion by 
blisters, followed by narcotic applications, in severe neuralgia ; friction 
of the surface with nutritious fluids in cases of extreme emaciation, and 
subcutaneous injection of narcotic solutions to relieve pain. 

339. The absorption of fluids less dense than the blood is easily 
accounted for by endosmose, which probably takes place chiefly through 
the coats of the capillaries or veins ; and it is by this means, as just 
stated, that poisons find their way into the system. But the absorbent 
vessels also take up and restore to the circulation the serum which has 
exsuded through the parietes of the capillaries, being the liquor san- 
guinis, minus the fibrine and corpuscles, that has been used to build 
up the solid textures of the body. By the absorbents, too, it is most 
probable that interstitial absorption is brought about. 

340. Of disordered functions of the absorbent vessels little is known. 
Formerly all dropsies were attributed to inaction of the absorbents, and 
such, remedies were given as were thought to stimulate those vessels. 
It was obviously reasonable to suppose, that the functions of the absor- 
bents, like those of other vessels, vary in activity at different times and 
under different circumstances ; but as the veins have been proved to 
possess the power of absorption as well as the lymphatics, it is difficult 
to assign to each class of vessels its proper sphere of activity, whether 
in health or disease. It has been shown, for instance, by direct experi- 
ment, that the veins absorb poisons ; but it is no less clearly demon- 
strated by disease, that some poisons excite inflammation in the entire 
course of the absorbent vessels, and in the glands through which they 
pass ; and this is attributed, and probably with justice, to the absorption 
of the poison by those vessels. 

341. But whatever the share taken in the work of absorption by the 
veins and absorbents respectively, there is no doubt that the part played 
by the absorbents in the production of dropsies has been much exagge- 
rated. These arise in various states of systems, and from various causes. 
Mechanical obstruction, venous congestion, inflammation, or debility, 
may give rise to an effusion of serum too abundant to be removed by 
the unaided, though still healthy, action of the absorbent vessels. If the 
obstruction be overcome, or venous congestion removed, or inflamma- 
tion subdued, or the strength restored, the effusion ceases, and time 
alone is required to enable the absorbent vessels, whether veins or 
lymphatics, to take up the fluid which has been poured out. 



THE CTRCULATIOX THROUGH THE LIVER. 75 

342. The doctrine that dropsies are generally due to inaction of the 
absorbents is in opposition to the notorious facts that patients suffering 
from dropsy are very readily affected by preparations of mercury, which 
must be absorbed before they can act, and that their adipose tissue is 
often rapidly removed, so as to occasion great emaciation. 

343. The known efficacy of venous distension in preventing absorp- 
tion, and of depletion in promoting it, point at once to the most effi- 
cacious means of removing dropsical effusions, viz., bloodletting, and 
the increase of the several secretions. If there is sufficient strength of 
constitution, these means suffice for their removal ; if not, tonics or 
stimulants have to be combined with the antiphlogistic measures. 

344. The removal of solid diseased structures has also been attri- 
buted to the increased action of the absorbents, but perhaps without 
sufficient reason. Pressure, friction, and electricity, as well as mercury 
and iodine, are as likely to affect the small vessels which cause the 
morbid growth, as the lymphatics or veins, which are instrumental in 
removing it — moderate pressure, by giving support to the vessels ; 
stronger pressure, by still further diminishing their size ; friction and 
electricity, by stimulating their coats and restoring their contractility ; 
and iodine and mercury, by a local action on those vessels, whether 
through the skin, or more circuitously through the circulation. The 
cessation or gradual removal of tumours by these agents is more 
satisfactorily explained in this way than by an action upon the ab- 
sorbents. 

345. In the case both of dropsies and tumours, the result would be 
the same, whether the small vessels, ceasing to secrete fresh fluids or 
solids, the absorbents, without increase of activity, remove by degrees 
that which has been effused ; or the vessels, continuing to secrete, the 
absorbents are excited to a corresponding increase of activity. The only 
difference is that, according to the first supposition, the cause is re- 
moved ; according to the second, the effect is counteracted. The first 
supposition seems the more feasible. 

346. The physiology and general pathology of the circulating system 
would be incomplete if reference were not made to the peculiarities 
that mark the circulation through the liver and through the brain. 

347. The function of the liver, and the nature of its secretion, have 
already been considered at some length in § 170 et seq. and § 243. The 
peculiarities of its circulation have yet to be described. The liver 
differs from the kidneys in being supplied for the purpose of secretion 
with venous instead of arterial blood. It is true that the solid consti- 
tuents of the urine are also secreted from blood which has previously 
been submitted to the action of the Malpighian tufts ; so that a circu- 
lation analogous to that of the portal system of the liver exists within 
the kidney. But in the liver (and this is true also of the lungs) the 
secretions are immediately derived from the venous blood. The vena 
portae is formed by the union of the veins of the stomach and intestines, 



76 PHYSIOLOGY AND GENERAL PATHOLOGY. 

of the spleen, pancreas, and gall-bladder, of the mesentery and omentum. 
With a slight and unimportant exception, it gathers the venous blood 
of the entire intestinal canal and of all the organs engaged in the work 
of digestion, conveys it to the liver, where the bile is secreted from it, 
and is poured into the duodenum to aid in the digestion of the food, 
and to subserve the function of respiration. The position of the liver, 
intermediate between the whole apparatus of digestion, on the one 
hand, and the right side of the heart and lungs on the other, explains 
its liability to congestion from fulness of the portal system no less than 
from impeded circulation through the lungs. 

348. The brain differs in some important respects from every other 
viscus. The viscera of the abdomen are contained in a yielding cavity 
with muscular walls ; those of the chest in a cavity consisting partly 
of bone and partly of muscle, but allowing of considerable increase and 
decrease of size in all directions ; but the brain is shut up in an un- 
yielding cavity of bone. All these cavities are air-tight ; but that of 
the cranium alone is both air-tight and unyielding, at least in the 
adult. It follows, then, that while all the cavities of the body must 
always be full, the cranium alone must always contain the same amount 
of matter, for the atmospheric pressure of 15 lbs. on every square inch 
of the surface of the body keeps the brain full, as it does a syphon. 
Now, the brain consists of a mass of nervous matter, supplied with 
blood by numerous vessels, and there is no reason to believe that this 
matter can suffer more compression than so much water ; so that the 
strongest pressure which can be exerted upon it in the living body 
would probably not be rendered perceptible by the most delicate instru- 
ment. It is also an undoubted fact that the brain of a healthy man is 
not affected by a change in ths pressure it ordinarily sustains. The 
descent in a diving-bell thirty-four feet below the surface of the water 
entails an extra pressure of 15 lbs. on every square inch of the body, 
but the brain does not suffer. On the other hand, the ascent of a lofty 
mountain, or going up in a balloon, materially lessens the pressure on 
the body, and, consequently, on the vessels of the brain, and yet the 
brain is not affected. The inhabitants of some of the valleys among 
the Andes, who live as far above the sea as the summit of Mont Blanc, 
suffer only half the pressure the body has to bear at the level of the 
sea, and yet they enjoy health bodily and mental. Again, the head 
of the infant suffers severe pressure during birth, and the yielding 
cranium of the child allows of large accumulations of fluid, and yet 
the brain suffers nothing during birth, and often very little in hydro- 
cephalus. 

349. Mere pressure, then, does not affect the functions of the brain, 
and yet when blood, or serum, or lymph are found on its surface or in 
the ventricles, or a tumour in its substance, or a larger quantity of blood 
than usual in some of its vessels, death is said to have been caused by 
pressure. This statement is inexact. There is encroachment or displace- 
ment of blood, but no pressure. The brain, like other organs of the body, 
is dependent for the due performance of its functions on its supply of 



THE CEREBRAL CIRCULATION. 77 

blood, and a tumour or fluid within the cranium, by occupying: space 
there, deprives the brain of a quantity of blood equal to its own bulk ; 
and the functions of the brain suffer in proportion to the loss. Those 
most open to observation are voluntary motion and sensation, both of 
which are lost or greatly impaired. The less obvious functions — the 
supply of nervous power to the more important viscera, especially those 
of circulation and respiration — are equally impaired : hence the infre- 
quent pulse and respiration. 

350. When blood is poured out suddenly, as in the common form of 
apoplexy, the symptoms are often more strongly marked, though the 
quantity of blood is very small, than in cases of slow effusion, or slow 
growth within the cranium, in which the brain adapts itself by degrees 
to the changes that are going on. If, in cases of apoplexy, the quantity 
of blood actually effused seems too small to account for the serious dis- 
turbance of the functions of the brain, we must take into account the 
injury which the texture of the brain itself has suffered, as well as the 
disturbance in the balance of the circulation that must have preceded 
and accompanied the rupture of the vessels. That this disturbance is 
in itself sufficient to account for the symptoms is evident from reported 
instances in which all the symptoms of apoplexy have been present 
without a single morbid appearance after death, except a dispropor- 
tionate quantity of blood in the veins and sinuses. 

351. Though the bony walls of the skull may, as already stated, 
be looked upon as unyielding, and the brain as incompressible, it is 
obvious that some slight change of position may take place at the open- 
ings by which the blood-vessels and nerves pass in and out of the skull, 
and that the intimate connection existing between the vessels of the 
brain and those of the scalp and face may become a source of relief 
and safety in sudden determinations of blood to the head. The flushed 
and turgid face of apoplectic seizures, and the engorgement or rupture 
of the vessels of the scalp, in cases of death by hanging or strangula- 
tion, are familiar consequences of this vascular connection. 

352. There are cases of apoplexy, then (that is to say, cases in which 
the functions of the brain are greatly impeded), for which no other 
cause can be assigned but a want of balance in the cerebral circulation. 
The arteries contain scarcely any blood, while the veins are full ; and 
it must be obvious that the brain thus imperfectly supplied is in as bad 
a condition as if it received no blood at all, or its vessels were filled 
with warm water. 

353. When the venous blood is less decidedly in excess, the functions 
of the brain, of course, suffer less ; and these slighter disturbances in 
the balance of the two circulations probably account for the conditions 
of the mind waking and sleeping. On the other hand, if the circulation 
through the arteries be increased, instead of torpor we have excitement 
characterised by heightened sensibility, strong muscular contractions, 
violent delirium, raving madness. 



78 PHYSIOLOGY AXD GENERAL PATHOLOGY. 

354. The balance of the circulation may be disturbed in various 
ways. Blood may be accumulated in the veins by pressure on the 
jugulars or on the carotid arteries ; for as the change of arterial into 
venous blood is constantly going on, an arrest of the circulation in 
either direction will increase the quantity of venous blood in the brain, 
and this will be followed by sleep, more or less profound, by coma, or 
apoplexy. External pressure, then, is one disturbing cause. An arrest 
of the heart's action, by putting a stop at once to the circulation through 
the brain, produces syncope, which differs from apoplexy merely in 
degree, the one arresting every function of the body, the other merely 
oppressing them. A very feeble action of the heart will be attended 
with a like result ; for the arteries receiving little blood, and the change 
from arterial to venous blood still going on, the brain will contain but 
a small quantity of arterial blood, and must consequently perform its 
functions imperfectly. Hence the deep sleep, or coma, which often 
attends extreme debility, and the turgid condition of the veins of the 
head when death follows upon haemorrhage or other exhausting cause. 
In these cases, however, an effusion of serum generally accompanies the 
turgescence of the veins. 

355. The incautious use of the lancet in cases of inflammation of the 
brain w T ould be calculated to produce this very result. The bold prac- 
titioner, not content with reducing the circulation through the arteries 
and veins to an equilibrium, carries depletion to the extent of greatly 
lessening the quantity of the circulating fluid, and enfeebling the heart's 
action. The arteries consequently receive little blood, the veins contain 
an undue proportion, the circulation through the brain becomes languid, 
serum is poured forth into the ventricles or on the surface, and the 
patient dies comatose. 

356. Sleep comes on, for the most part, at that period of the day, 
and in that posture, in which the circulation is most sluggish, viz., at 
night, and lying down. As a general rule, the pulse falls towards 
evening, and it is also less frequent in the horizontal than in the erect 
posture. These two circumstances, then, which favour a slow T circula- 
tion, also favour sleep, and partly explain its occurrence. But other 
causes must be taken into account, such as the darkness and silence, the 
absence of the usual impressions on the senses, and the exhaustion of 
the nervous system, this exhaustion reacting on the circulation, and the 
circulation, in its turn, reacting on the brain. Sleep ; then, may be 
considered as due partly to exhaustion of the nervous system, partly to 
the absence of impressions on the organs of sense, and partly to the 
languid eh dilation through the brain. Intense cold, another familiar 
cause of sleep, probably acts partly by causing an accumulation of 
blood in the internal organs, and partly as a direct sedative. A languid 
cerebral circulation will result on either supposition. In the cold stage 
of ague, the same state of circulation exists, and the same condition of 
brain. 

357. Among other causes of sleep may be mentioned repletion, and 



STRUCTURAL PHYSIOLOGY AND PATHOLOGY. 79 

a certain stage of intoxication, the one leading to the circulation through 
the brain of the products of digestion not fully converted into blood ; 
while spirituous liquors act as a poison, stimulant in a small dose, and 
narcotic in a larger one. 

358. The cerebral circulation varies much with the posture of the 
body. In the erect posture, the heart, in sending blood to the brain, 
has to oppose the force of gravity ; but in the horizontal posture it has 
much less resistance to overcome. Hence, when the heart is feeble and 
the system drained of blood, a sudden change from the recumbent to the 
sitting or erect posture will sometimes cause fatal syncope ; and, on the 
other hand, a patient who has fainted in the erect posture is soon re- 
stored by being laid on the back. When the head is lower than the 
rest of the body, the return of blood to the heart is opposed by gra- 
vity ; the balance of the circulation is therefore destroyed, and coma is 
threatened. This unfavourable position, combined with sudden exertion, 
as in stooping to tie a shoestring or pull on a boot, is an occasional cause 
of apoplexy. 

359. The fact that the flow of blood to the head is favoured by the 
recumbent, and retarded by the erect posture, suggests the proper treat- 
ment of disease of the brain. When there is high arterial action, the 
head should be raised ; where there is great exhaustion, the body should 
be laid horizontally. Such changes of posture are often attended with 
the best effects : thus instances are recorded in which pain, intolerable 
in the horizontal posture, has been at once removed by assuming the 
erect position. 

360. When, again, it is desirable to produce a sudden and strong 
effect on the system by the abstraction of blood, or to obtain the greatest 
effect with the least expenditure of blood, the patient should be placed 
in the erect posture, for the heart soon loses the power of sending the 
blood upwards to the brain, and fainting ensues. 

361. Wakefulness, excitement, and delirium are the direct opposites 
of the states of drowsiness and sleep, and arise from an opposite state of 
the cerebral circulation. The degree of violence displayed bears a pretty 
exact relation to the rapidity and force of the arterial circulation, and to 
the strength of the patient. In the strong and robust, the outward 
manifestations in delirium are violent, and the muscles contract with 
great force ; but if the strength is much exhausted, the loud talking of 
furious delirium is exchanged for low muttering ; the violent muscular 
efforts for subsultus tendinum ; and the distinct impressions on the 
senses for muscee volitantes, and tinnitus aurium. 

3. STRUCTURAL PHYSIOLOGY AND PATHOLOGY. 

362. In the two previous chapters the human body has been exa- 
" mined: first, as a chemical laboratory, in which the functions of diges- 
j tion, assimilation, and sanguification are carried on; and, secondly, as 
j an hydraulic system, by which the blood is collected and distributed. It 



80 PHYSIOLOGY AXD GENEEAL PATHOLOGY. 

is next to be considered as an assemblage of minute structures, by which 
all its parts and organs are built up. 

363. It has been already stated that the circulating system, consist- 
ing of arteries, capillaries, and veins, forms a continuous and unbroken, 
though most minutely-divided, reservoir of blood in motion. The 
arteries serve as carriers of pure blood to the several tissues, the veins 
as carriers of impure blood from them, while the capillaries, the imme- 
diate agents of growth and nutrition, connect the two classes of vessels. 

364. As the capillaries have no open mouths, the tissues can be 
nourished only by transudation through their walls. The fluid em- 
ployed in this work of nutrition is the liquor sanguinis ; in other words, 
the blood itself less its red particles. As the liquor sanguinis contains 
albumen and fibrine, and all elementary substances necessary to nutri- 
tion, it is obviously equal to the use thus assigned to it. Alany of the 
capillaries transmit only this colourless liquid. 

365. The liquor sanguinis exsuding through the coats of the capil- 
laries, and brought into contact with the tissues, subserves the purposes 
of nutrition and growth, by being converted into cells (Schleiden and 
Schwann) or k * germinal matter " and '' formed material " (Beale). 

366. According to the first-named authorities, all the tissues of the 
body are made up of cells, which consist originally of three distinct 

parts : — c, the cell-membrane ; 6, the nucleus, or cyto- 
Fig. 5. blast ; and a, the nucleolus. The cells are developed in 

a fluid termed the cytoblastema, or cell-producer. In 
the case of the healthy tissues and of the new textures 
generated by healthy inflammation, this fluid is the 
liquor sanguinis. The cell containing, and being sur- 
rounded by, a fluid similar to that from which it was 

formed, increases in size, and similar cells, with the same constituent 

parts, form either within it or external to it. 

367. The cells, which have the rounded form of Fig. 5, when floating 
in the cytoblastema, may press against each other, so as to assume the 
hexagonal form that vesicles so circumstanced always put on. If the 
intervals between the cells are supposed to be occupied by a firm un- 
organized deposit, we have the essential elements of such hard tissues as 
cartilage or bone. Jf, instead of being round or oval, they assume 
elongated forms, we have the elements of the fibrous tissues ; and, 
lastly, if cells arranged in lines with their ends in apposition are sup- 
posed to have their opposed terminal walls removed by absorption, we 
have such hollow tubes as arteries, veins, absorbents, and the sheaths of 
the nervous matter. 

368. Cells also enter into the composition of some of the fluids both 
in health and disease. The red particles which float in the liquor 
sanguinis of the blood are nucleated cells ; so also are the lymph glo- 
bules ; and the mucous and purulent secretions thrown out from 
inflamed surfaces contain mucous and pus-globules. 



-&» 




HYPERTROPHY AND ATROPHY. 81 

369. In healthy pus formed on the surface of a wound, these 
pus-globules become organised, and constitute successive layers of granu- 
lations. The superficial layers present cells which resemble the pus- 
granules ; the deeper strata consist of cells of which the nuclei are very 
distinct, and the envelopes polygonal from mutual pressure ; while in 
the deepest layers of all the envelopes of the cells are seen passing through 
all the gradations of the fibres of areolar tissue. — (Henle.) 

370. The cell-theory also admits of application Fig. 6. 
to malignant growths. The liquor sanguinis, or .^ 
cytoblastema, which exsudes through the capillaries, ^ r _^_ yKy 
instead of furnishing the materials for healthy cells 
to build up healthy tissues, supplies the elements of 
cells of the irregular shape of those depicted in the 
annexed engraving, and which form a constituent 
part of cancer. 

371. For this cell -theory of Schleiden and 

Schwann, Dr. Beale has substituted a simpler account of the minute 
constituent parts of living beings. He supposes a spherical particle of 
germinal or active matter, which itself consists of spherical particles of 
extreme minuteness, and an outer sphere of formed or inactive materials. 
This germinal matter may surround itself with successive layers of formed 
material. If there happen to be two such layers, the outer will corre- 
spond to the cell membrane, and the inner to the nucleus, while the 
central germinal matter is itself the nucleolus. This central germinal 
matter alone possesses active formative properties, and appropriates and 
assimilates the liquor sanguinis with which the tissues are bathed. 

372. Both these theories admit of application to diseased as well as to 
healthy growths ; but many morbid changes involve not the minute 
elementary parts only, but the aggregate structures which they serve to 
build up. 

373. One class of structural changes, for instance, consists in a simple 
mechanical enlargement of hollow organs, such as the stomach, large and 
small intestines, and urinary bladder, trom habitual distension ; of the 
veins of the extremities from pressure on the large venous trunks ; and 
of the anastomosing branches of arteries as a consequence of the applica- 
tion of a ligature to the main trunk. 

374. A second class of structural changes consists in abnormal nutri- 
tion, in excess or defect, without any change in the minute texture 
of the parts affected. The former is called hypertrophy ; the latter, 
atrophy. 

375. The principal cause of hypertrophy is increased action ; of which 
illustrations are afiorded by the muscles of the athlete, by the heart and 
bladder when they encounter an obstacle to the evacuation of their con- 
tents, by the uterus during pregnancy, by the mammae of the female 
when secreting milk, by the mucous membrane of the bladder exposed 

G 



82 PHYSIOLOGY AXD GENERAL PATHOLOGY. 

to irritation from stone or gravel, and by the small arteries in organic 
disease of the viscera which they supply. 

376. Atrophy arises from opposite causes ; from disuse of parts, as 
of the muscles in the sedentary, paralytic, and bedridden, from obstruc- 
tion to the flow of blood by ligatures, or from the operation of such 
powerful medicines as iodine and the salts of lead. Internal organs may 
also become atrophied from a cause describe! in § 384. Atrophy is 
marked by paleness of the parts affectei, as hypertrophy by increase 
of colour. 

377. Hypertrophy and atrophy are sometimes limited to one consti- 
tuent part of a texture. Thus bone may become unusually hard from 
the crowding of many earthy particles into the space commonly occupied 
by a few, or soft, from absence of the earthy matter. 

378. A third class of structural changes consists of the effects ot 
common inflammation (§ 291, et seq.), due to common causes. 

379. A fourth class comprises the effects of inflammation due to 
specific causes — to poisons introduced into the body from without by 
insertion or inoculation, by application to the skin, by inhalation through 
the lungs, or by admixture with food or drink. The local effects, direct 
and transferred, produced by wounds received in dissection, by syphilis, 
by mercury, arsenic, lead, copper, and phosphorus used in the arts, by 
the contagion of plague typhus fever and the exanthemata, and by 
drinking water polluted by the contents of drains and cesspools, afford 
examples in point. 

380. A fifth class consists of those which are brought about by causes 
acting within the body itself, originating in the blood-vessels, and pro- 
ducing structural changes either by simple mechanic al impediment or by 
a taint imparted to the blood. To the first class belong the fibrinous 
clots formed in arteries or veins, or in the heart itself, which may either 
continue in the spot where they were formed, or be transferred by the 
current of the circulation to some smaller vessel often very remote from 
the origin of the mischief, there to give rise to obstructed circulation and 
consequent structural change. To the second class belong those local 
abscesses in the liver, lungs, serous cavities, and joints which spring up 
as a consequence of the blood becoming the carrier of purulent matter 
formed in some venous trunk or in the open mouths of veins wounded 
or otherwise exposed. The mechanical impediments of the first class are 
now familiarly known by the names of thrombus and embolus ; the puru- 
lent deposits of the second class as secondary abscesses. 

381. The structural changes or morbid growths resulting from these 
several causes have been grouped in two leading classes, under the 
designations analogous and heterologous, analogous formations being 
those that resemble the natural tissues, heterologous those that differ 
from them. 

382. The class of analogous formations is a very important one, and 



FATTY DEGENERATION — ATHEROMA . 



83 




comprises some of the most fatal diseases of the secreting organs, espe- 
cially of the liver and kidney, as well as several morbid states of the 
heart and of the arteries, giving rise to fatal structural changes in the 
organs which they supply. 

383. Fatty Degeneration. — Deposits of fat or oil-globules constitute 
the disease known as fatty degeneration of the liver, as well as certain 
forms of Bright's disease of the kidney. The oil-globules are deposited 
in the epithelial cells of the 
secreting surfaces, and in the 
cellular tissue connecting the 
vessels. The annexed illustra- 
tions show the mode in which 
the oil-globules are deposited in 
the cells of these organs. In 
Fig. 7, a represents healthy 
cells of the liver, free from oil- 
globules ; and b, cells from a 
liver in a state of fatty dege- 
neration. In Fig. 8, a repre- 
sents healthy epithelial cells of 
the kidney, and 6, cells loaded 
with oil-globules. In disease 

of the kidney, the secreting tubes lined with cells containing oil-globules 
are expelled with the urine, so as to furnish evidence during life of the 
character of the disease. 

384. The first effect of these abnormal deposits is to increase the size 
of the diseased organs without materially affecting their functions ; but 
as the disease advances the fatty deposits encroach more and more on the 
vessels and secreting apparatus, so as on the one hand to restrict the 
supply of blood, and on the other to impair the secreting power of the 
cells. Hence, in extreme cases, the organs affected are rendered ancemic, 
and become quite unequal to the performance of their functions ; and 
instead of increasing in size, they lose bulk from the cessation of nutri- 
tion and the absorption of the oil -globules, which were the original cause 
of the disease. 

385. But deposits of oil or fat are not limited to the secreting organs : 
they take place also in the tissues. They are laid down, for instance, in 
the muscular structure of the heart, and enfeeble it by encroaching on 
and displacing the healthy muscular tissue. 

386. Associated with earthy matter, as atheromatous deposits, they 
occur in the coats of arteries, which are often found to be the seat of 
this species of degeneration in subjects affected by similar disease of the 
liver and kidneys. These deposits ate situate either in the cellular 
membrane between the inner and middle coats, or in the fibres of the 
middle coat itself. When they occur in the middle coat of the larger 
arteries, they take the place of the healthy structure, impair its elas- 
ticity, and lead to dilatation. In the smaller vessels they are often so 



84 



PHYSIOLOGY AXD GEXEKAL PATHOLOGY. 



Fig. 9. 



abundant as to obliterate their channels, and thus cut off the supply of 
blood from the parts to which they are distributed. When this occurs 
in the coronary artery of the heart its muscular substance becomes 
atrophied. These deposits are found to obey the law of symmetry, 
attacking equally and similarly the vessels on both sides of the body. 

387. Atheromatous deposits in the coats of arteries often become the 
seat of ulceration, leading to perforation and sudden death from haemor- 
rhage. When the ulcers make their way through the inner coat of the 
arteries, they project from it as ragged uneven tumours, and when they 
occur in the aorta, are frequent causes of abnormal blowing and sawing 
sounds. In other cases the atheromatous spot becomes the nidus of cal- 
careous deposit, in which case the vessel is said to degenerate into bone. 

388. The small vessels of the brain are also subject to fatty degenera- 
tion. Oil-globules are deposited in the transverse fibrous coat of the 

arteries,, and in the corresponding coat of 
the veins. They may be seen under the 
microscope, either as " minute, shining, 
black-edged particles, like molecules of 
oil, thinly and irregularly scattered be- 
neath the outer surface of the small 
blood-vessels ," as globules of larger size, 
more closely packed together, or in round 
or oval clusters, "like large granule-cells." 
The subjoined engraving, from a paper by 
Paget, in the " London Medical Gazette," 1850, shows the micro- 
scopic appearance of small arteries under this form of degeneration. 

389. This deposit of oil- globules destroys the even outline of the 
vessels, and, their proper structures gradually wasting, the smaller vessels 
dilate into minute aneurismal pouches. The proper vascular structure 
being thus weakened, softening of the brain ensues, followed by rupture 
of the vessels. This is one form of apoplexy. 

390. Another analogous formation consists in a deposit of semi-car- 
tilaginous matter on the free inner surface of the arteries. Its most 
common seats are the valves of the heart and aorta, the larger vessels at 
the points where they give off branches, and the smaller arteries through- 
out their whole extent. Calcareous deposits, having the hardness of 
bone, are also of frequent occurrence in the heart and arteries as inde- 
pendent formations ; that is to say, they take place where the structures 
have not previously undergone any other form of degeneration. The 
fibrinous deposits which attach themselves as vegetations to the lining 
membrane of the heart, especially to that covering the valves, afford 
another familiar example of analogous formation. 

391. Recent researches have attached a new and unexpected interest to 
these valve- deposits. They occasionally become detached from the mitral 
valve, and, being borne forward by the current of the circulation, lodge 
in an artery of the brain, impede or stop the circulation through it, cut 




HETEROLOGOUS FORMATIONS — TUBERCLE. 85 

off the supply of blood to a part of the brain, which becomes softened, 
and so gives rise to hemiplegia. This formidable accident is now grown 
familiar to us under the name of embolus, or embolism. 

392. Another instance of fatty degeneration has been pointed out by- 
Mr. Canton in the circus senilis, or white line, seen just within the cir- 
cumference of the cornea in many aged persons, in some who have 
passed the middle of life, and occasionally as early as 35 years of age. 
It is sometimes associated with fatty degeneration of more important 
organs. Fatty degeneration of the ovum has also been shown to be a 
frequent cause of abortion. 

393. It will be seen, then, that deposits of oil-globules or fat, whether 
in the cellular membrane uniting the vessels of secreting organs and in 
the coats of arteries, or in the epithelial cells of secreting membranes; 
whether continuing in their original form, and encroaching gradually on 
the healthy structure of the organs they attack, or becoming the seats of 
ulceration, or of calcareous deposit — play a most important part in the 
history of organic disease. 

394. These fatty deposits may sometimes be confidently traced to im- 
perfect oxygenation of the venous blood. Fatty degeneration of the 
kidney, for instance, is a common occurrence both in men and animals 
living in dark, filthy, and ill-ventilated places, where the air is unfit to 
support the process of combustion in all its vigour, at the same time 
that the constitution is enfeebled. Again, fatty degeneration of the liver 
and kidneys, atheromatous deposits in the arteries, and fatty degenera- 
tion of the heart, are often found associated in the spirit-drinker, who 
constantly introduces into his system a large supply of a liquid hydro- 
carbon, of which the gaseous elements attract the oxygen that ought to 
be devoted to the combustion of the carbonaceous matters derived from 
the food, and from the effete textures of the frame. 

395. French epicures by producing fatty livers in geese, through a 
combination of high feeding and heat, have given us another lesson as to 
the causes of this diseased condition — causes which find their combined 
application in the production of liver disease in Europeans who carry the 
dietetic customs of England to the hot climate of India. 

396. Heterologous Formations. — These morbid growths may be di- 
vided into two classes — non-malignant and malignant. The first com- 
prises tubercle, the second the several forms of cancer. Tubercular 
diseases generally fall under the care of the physician ; malignant dis- 
eases more commonly into the hands of the surgeon. But both classes 
may attack either the internal or external organs of the body. 

397. Non-malignant Diseases. Tubercle. — This is deposited on the 
surface of membranes, or in the texture of organs. It has two different 
forms — the one, whitish-grey, semi-transparent, and dense ; the other, 
yellow, opaque, and friable. The first may be changed into the second, 

but the second is never transformed into the first. The grey tubercle 



86 PHYSIOLOGY AND GENERAL PATHOLOGY. 

is found in small isolated portions in the air-cells of the lungs as miliary 
tubercles, or on the surface of serous membranes. The yellow variety is 
found in the same situations, as well as on the surface of mucous mem- 
branes, and in the substance of organs — in the follicles of the intestines, 
in lymphatic glands, in the liver, spleen, brain, uterus. &c. It assumes 
different forms in different situations. It may be collected in a distinct 
mass, or diffused through the tissues of an organ as a homogeneous cheesy 
matter ; or it may be so thoroughly blended with the textures as to assume 
the verv form of the organ attacked, which is then said to degenerate into it. 

398. Tubercle consists of albumen, fibrine, gelatine, salts of soda and 
lime, and water, with a little fatty matter. Under the microscope 
miliary tubercle presents the appearance of granules blended with 
nucleated cells, or tubercle corpuscles. The yellow variety also consists 
chieflv of granules, interspersed with minute spherules, irregular flakes, 
and numerous oil-globules, edged with a few perfect cells. 

399. Tubercle is rarely deposited before birth ; is not common before 
the fourth year ; is frequent between the fourth and fifth ; less frequent, 
ao'ain, from this time till puberty ; most frequent of all between puberty 
and the age of fifty. The lungs are its most common seat, so that after 
fifteen it is almost never met with in other organs without existing in 
them at the same time. The state of constitution {tuberculous cachexy) 
which leads to tubercular deposit may be either inherited or acquired. 

400. Tuberculous matter is deposited slowly, without causing pain or 
inconvenience, and may remain quiescent for a very considerable period. 
At length, in the course of a common cold, or slight febrile attack, the 
tubercle begins to act as a foreign body, and sets up inflammation in the 
surrounding tissues. When this change takes place in the absorbent 
glands, serum and pus are poured out, and an abscess is formed, which 
slowly approaches the surface, bursts, and discharges the tubercle 
softened and broken down by the effused fluids. The w^alls of the 
abscess then generally contract and heal. Tubercles in the lung undergo 
the same change, the matter being expectorated ; but sometimes they 
are converted into a chalky or earthy matter, and remain quiescent for 
the rest of life. When the deposit is on the mucous membrane of the 
larynx or intestines, the membrane ulcerates. 

401. Scrofulous subjects are not only liable to tubercular deposits, 
but also to the chronic forms of inflammation, suppuration, and ulcera- 
tion. The lymph effused, as the result of inflammatory action, is curdy, 
and wanting in consistence, the pus serous and flaky, and granulations, 
when formed, are large, pale, and flabby. Pustular, scabby eruptions 
of the ears and mouth, discharging a thin acrid matter, enlarge- 
ment, inflammation, and suppuration of the absorbent glands, especially 
of the neck, and a similar atiection of the mesenteric glands, are also 
common in scrofulous children. 

402. It has been shown experimentally that tubercular deposits may 
be produced at will in animals by confining them inclose dirty places, and 
feeding them on unwholesome food. 






MALIGNANT DISEASE — CANCER — MELANOSIS. 87 

403. Malignant Diseases. — These heterologous formations resemble 
tubercle in affecting almost all the organs of the body ; in being fre- 
quently traceable to hereditary predisposition ; and in their tendency 
to excite destructive inflammation of the parts affected. On the other 
hand, malignant growths are distinguished by extending into sur- 
rounding textures, stirring up inflammation in them, and progressively 
destroying them ; by following the course of the absorbents and attacking 
the lymphatic glands ; and by reappearing, after removal, in or near 
the cicatrix, or in some internal organ nearly connected, through the 
absorbent system, with the part first attacked. The true malignant 
growths may be all comprised under the general name of Carcinoma or 
Cancer. 

404. Carcinoma [Cancer). — This term was originally applied to a 
malignant nicer supposed to bear a resemblance to a crab (Kapnivos. 
cancer). It now comprises many changes of structure differing widely 
in their physical characters: as scirrhus. or hard cancer ; medullary, or 
soft cancer (with its most vascular form, fungus ha?matodes) ; epithelial 
cancer ; melanotic cancer (characterised by the presence of pigment) ; 
osteoid cancer ; and colloid cancer, characterised by the transparent or 
gelatinous substance of which it consists. They are all made up of com- 
pound cysts varying in their solid and fluid contents, growing from 
broad bases, or from narrow peduncles, which, springing from a single 
spot, give to the tumour a radiated appearance. The various appearances 
presented by these tumours are partly due to the inflammation w 7 hich 
takes place in them and in the surrounding textures, and partly to the 
entire or broken state of the cysts themselves. 

405. Melanosis. — This is an unorganized product, of a dark brown, 
dull bistre, or sooty-black colour, deposited in masses with or without 
cysts, or in patches on membranous surfaces. Sometimes it is met with 
in small points, and occasionally it has been found liquid. Its most fie- 
quent seat is the liver ; but it is sometimes found in the eye, skin, brain, 
lungs, kidneys, and other glandular organs. Its chemL-al constituents 
are albumen, flbrine, and the salts usually found in the blood, with a 
colouring matter abounding in carbon. When associated with malig- 
nant growths, the cells, instead of continuing free, are attached to the 
surrounding tissue. Deposits of a black colouring matter are often 
found in the bronchial glands and on the surface of the lungs both before 
and after birth, buch deposits are not malignant. 

406. This account of structural physiology and pathology would be 
incomplete if some notice were not taken of the large number of non- 
malignant tumours and cysts with which the surgeon has to deal : such 
as the fibrous, nbro-cellular, fibro-nucleated, ribro-plastic, myeloid, 
fatty, osseous, cartilaginous, fibro-cartilaginous, and vascular, among 
tumours, and the simple or barren, and compound or proliferous among 
cysts. Some notice should also be taken of the intractable, but not 
malignant, disease that attacks chiefly the integuments of the face, 
under the name of lupus, with its chronic form, and the more acute 
variety known as lupus exedens. 



88 



PHYSIOLOGY AND GENERAL PATHOLOGY. 



vjj 



4. THE NERVOUS SYSTEM. 

Fig. io. 407. It is not possible to represent in 

a single diagram ( such as that which, at 
p. 57, is used to illustrate the mechanism 
of the circulation) that complex airange- 
ment of nerve - masses and nerve - fibres 
known as the nervous system. The brain 
and spinal cord, shown in plan in Fig. 10, 
and the brain, shown in vertical section in 
Fig. 11, are but the conspicuous parts of 
a whole which requires the sympathetic 
nerve for its completion, and of which the 
delicate terminations are to be found, accom- 
panying the smallest vessels, in every organ 
and texture of the body. 

408. The brain, of which the base, with 
the nine pairs of nerves arising from it, is 
shown in Fig. 10, and the vertical section, 
displaying the three leading divisions (cere- 
brum, cerebellum, and medulla oblongata), 
in Fig. 11, is the centre to which all sen- 
sations are referred, and from which all 
voluntary efforts originate. The spinal 
cord, with thirty - one pairs of nerves 
springing from it, for distribution to the 
trunk and limbs, may be said to occupy an 
intermediate position between these nerves 
and the brain ; while the brain and spinal 
cord together form the joint source from 
which all the nerves of sense and of volun- 
tary motion arise, from which all the man- 
dates of the will are sent forth, and to which 
the intelligence of every sense is conveyed. 
From these centres, too, those nerves which 
control the movements of respiration and 
circulation take their rise. The sympa- 
thetic nerve, connecting itself with the 
several nerves of sensation and volition 
which spring from the brain and cord, pre- 
sides over the functions of many of the 
organs most essential to life, is the source 
of some of those movements which are in- 
dependent of the will, of many of those 
sensations by which life is preserved, and 
of the chemical changes that are peculiar 
to living beings. The spinal marrow, 
aojain, is the centre of union of certain 



FUNCTIONS OF THE NERVOUS SYSTEM. 



89 




nerves which form with it the excito-motory system, the seat of the 
reflex function. One set of nerves passing from the skin and mucous 
membranes convey to the cord 

certain impressions which, not Fig 11. 

passing onward to the brain, 
are not perceived ; while ano- 
ther set, arising from the cord, 
and being distributed to the 
muscles, give rise to contrac- 
tions which, as the impulse 
does not originate in the brain, 
are involuntary. This excito- 
motory system and reflex- 
function bear a very import- 
ant part in all those move- 
ments which subserve the 
most pressing wants of the 
frame, such as the ingestion 
of food, and the supply of 
air in breathing. Lastly, the 
cerebellum has been shown to 
be the centre and source of a 
co-ordinating function, or har- 
monising control, exercised over those voluntary muscles which have 
come to act in unison for the production of certain complex movements, 
such as those of standing, walking, working with the arms and fingers, 
speaking, and singing. 

409. The following scheme, then, represents the leading functions of 
the nervous system, as well as the portions of the nervous centres by 
which they are performed : 

(1.) Sensation and voluntary motion, of which the brain is the centre. 

(2.) Co-ordination of voluntary movements, of which the cerebellum 
is the centre. 

(3.) The excito-motory, of which the true spinal cord is the centre. 

(4.) The nutrient and secretory, of which the sympathetic or gan- 
glionic system forms the principal portion. 

410. (1.) The first order comprises all the nerves of sensation (the 
olfactory, the optic, the auditory, the gustatory, and the nerves of touch), 
and all the nerves of voluntary motion, with their common centre in 
the cerebrum. The greater part of the nerves of touch, or common 
sensation, and the nerves of voluntary motion form the external portions 
of the spinal marrow, and through it communicate with the brain. 

411. (2.) Of the second order it must suffice to state that pathology 
and experiment combine to prove that the cerebellum, with the posterior 
columns of the spinal cord, which are downward prolongations of it, is 



90 PHYSIOLOGY AND GENERAL PATHOLOGY. 

the centre of a co-ordinating function voluntarily exercised over the motor 
nerves. The reason for associating the posterior columns of the cord 
with the cerebellum as the seat of this function are : — that they are not 
sentient, that motion is not destroyed when they are divided, but that 
by such division muscular movements are thrown into disorder. 

412. (3." The third order consists of two sets of nerves, of which the 
one passes chiefly from the mucous surfaces to the interior parts of the 
medulla oblongata and spinal cord, and the other from those parts of 
the medulla and cord to muscles which are chiefly subservient to inges- 
tion and egestion. Some fibres of the same order of nerves are probably 
distributed to the skin and voluntary muscles. That part of the spinal 
marrow to which these nerves run has been called the true spinal mar- 
row, in contradistinction to those parts of it which are formed by longi- 
tudinal 'commissural | fibres going to the brain. The motions due to 
this system are said to be excited, and the nerves are distinguished as 
afferent and efferent, incident and reflex. Through these nerves the 
mouth of the infant, when applied for the first time to the mother's 
breast, performs the movements of suction — movements which take place 
even in the acephalous infant ,- through them, too, the contents of the 
bladder and rectum are expelled ; and foreign bodies discharged from 
the air-passages by sneezing and coughing. 

413. The third class of nerves, or the ganglionic, consist of the inter- 
nal ganglionic, or sympathetic, including a few fibres of the pneumo- 
gastric ; and the external ganglionic, embracing the fifth nerve and the 
posterior roots of the spinal nerves. These latter are supposed to be 
chiefly destined for the nutrition of the external organs. 

414. The leading functions of the nervous system, then, are: — 1, 
sensation and voluntary motion ; 2, co-ordination of muscular move- 
ments ; 3, excitements to action without sensation, and combined motions 
without volition ; and 4, nutrition, secretion, and the motions connected 
with them. To these must be added the mental functions, which have 
their seat and organ in the cerebrum, and which will have to be con- 
sidered in the next section. 

415. The nerves consist of bundles of minute fibres, enclosed in 
sheaths, distinct through their entire course, and connected at their 
origin with a nerve vesicle. They remain unbroken till they arrive at 
the part to which they are distributed, when they begin to branch freely, 
and, uniting with similar branches of other nerves, form at last networks 
of excessive tenuity. 

416. Experiment has revealed to us the functions of the more im- 
portant nerves, but has left much yet to be discovered. It has also 
thrown light on the laws that govern the transmission of nervous force, 
though it has left the nature of that force involved in the same obscurity 
which hangs over the real essence of light, heat, or electricity, with 
which last, however, it appears to have many points in common. 

417. The effect of the division of a nerve is well known. If it be 



FUNCTIONS OF THE NERVES. 91 

one of sensation, irritation of its branches or trunk below the point of 
division causes no pain ; if it be one of voluntary motion, neither the 
will nor a stimulus applied to it above the point of division can cause the 
muscle to which it is distributed to contract. On the other hand, if the 
voluntary nerve be irritated below the point of division, or the sentient 
nerve above it, motion takes place in the one case, and sensation in the 
other ; the sensation being referred to the pai ts to which the nerve is 
distributed. This law of sensation is strikingly illustrated in cases of 
amputation of a limb. Irritation of the cut end of the nerve is referred 
to the fingers or toes of the lost limb for years after its removal. 

418. The fact that irritation of the trunk of a sentient nerve causes 
pain, not in the trunk itself, but in the parts to which its branches are 
distributed, admits of practical application, and tends to destroy confi- 
dence in the division of nerves as a remedy for pains in the p:irts they 
supply. But the failure of this remedy in some cases has been explained 
by the discovery of some permanent cause of irritation, such as a tumour 
or spicula of bone, at the origin of the nerve. 

419. Pressure applied to a sentient nerve causes pain in the parts 
supplied by its branches, but a firmer pressure produces pain in the 
trunk of the nerve itself. Severe injury to a nerve of sensation or volun- 
tary motion destroys its power as a conductor of nervous force, but it 
affects the nerve itself only locally ; for irritation of the part of the un- 
injured sensitive nerve connected with the brain causes sensation, and 
irritation of the part of the nerve of volition connected with the muscles 
excites muscular contraction. When, however, a nerve of motion is 
stretched violently through its wmole length, it can no longer conduct 
the stimulus of muscular contraction, and sometimes the muscle itself 
loses its irritability, and cannot be made to contract by the most powerful 
stimulus. 

420. Experiments on animals have brought to light other properties 
of the nerves which may be advantageously borne in mind by the patho- 
logist. It has been proved that all stimulants applied to the nerves of 
the dead body act nearly in the same way, though with different inten- 
sity ; but the electric and galvanic fluids being the most effectual, are 
generally selected for experiment. It has also been shown that the motor 
nerves, under the stimulus of galvanism, do not act as mere conductors 
of the galvanic fluid, for the muscles contract when the current is made 
to pass transversely through them. The muscles, however, cannot be 
made to contract by any degree of mechanical irritation applied to a 
nerve of sensation, while the slightest irritation of a nerve of motion 
gives rise to very strong contractions. Hence it appears that the motor 
nerves themselves can excite muscular contractions on the application of 
stimuli, independent of the brain and spinal cord. It has been further 
shown that this property may be exhausted by the continued application 
of a stimulus, to return after an interval of rest. 

421. These experiments on dead animals are in accordance with the 
results of observation in the living human body. The exhausted ner- 



92 PHYSIOLOGY AND GENERAL PATHOLOGY. 

vous power must be restored by rest ; the exhaustion of the entire frame 
repaired by sleep ; and stimuli, whether mechanical, chemical, or elec- 
trical, cause the nerves to which they are applied to manifest their cha- 
racteristic properties. Irritation of a nerve of common sensation causes 
pain ; of a nerve of motion, muscular contraction: and the stimulus of 
galvanism excites in each organ of sense the sensation proper to it- taste 
in the tongue, a peculiar odour in the nose, lis;ht in the eye, a musical 
sound in the ear. Lastly, irritation of the origin of the pneumo-gastric 
nerve gives rise to a derangement of the digestive process manifested by 
the elimination of sugar from the kidney. 

422. The stimulants, heat, cold, and electricity are use I as remedial 
agents. Both heat and cold cause the muscles to contract, and, when 
excessive, destroy their irritability. Cold water injected into an artery 
causes contraction in the muscles which it supplies ; hence, in uterine 
haemorrhage following delivery, cold water is injected with effect into 
the vessels of the still- adhering placenta, and cold suddenly applied ex- 
ternally or internally causes contraction of the uterus. The good effect 
of electricity and galvanism is manifested in some cases of paralysis. 

423. Stimuli of great intensity can destroy the excitability of the 
nerves, as happens with the optic nerve when a flash of lightning pro- 
duces permanent blindness ; and with the brain and spinal cord when 
it causes sudden death. Permanent paralysis may arise from the same 
cause. A weaker stimulus applied for a longer time may produce the 
same effect. Thus, snow blindness sometimes follows the continued 
strong reflection of light on the retina, and paralysis of the muscles 
violent and long-continued exercise. Weaker stimuli, or the same stimuli 
applied for a shorter period, impair the excitability of the nerves and 
cause fatigue. Thus the eye fixed for a long time on the same colour 
becomes insensible to it; and if the same set of muscles is kept in action 
only for a few minutes, as when we hold an arm extended, or stand 
quite still, we feel extreme fatigue, from which the slightest change of 
posture affords instantaneous relief. 

424. Nervous exhaustion is always accompanied by severe pain. 
Thus, the long-continued application of the stimulus of light to the eye, 
or of cold or heat to the skin, gives rise to acute suffering ; and prolonged 
action of the muscles in w T alking may occasion the most excruciating agony. 

425. A stimulus, then, applied to the nerves of sensation or voluntary 
motion, produces, according to its degree and duration, entire destruction 
or great exhaustion of the nervous power, accompanied in extreme cases 
by severe suffering ; and the functions of the nerves are not restored till 
after rest proportioned to the exhaustion. The brain and spinal cord 
are the sources of the restorative influence, and motor nerves, permanently 
cut off from those centres, lose their property of exciting muscular 
contraction. 

426. Stimuli, therefore, first excite the nerves, and then exhaust them. 
But there are substances known as narcotics which have the effect of 



THE SYMPATHETIC. 93 

deadening the excitability of the nerves, and, in a concentrated form, ot 
entirely destroying it. If, for instance, the ischiatic nerve of a frog be 
dissected, and allowed to hang in a solution of opium or morphia, the 
nerve is deprived of its power of exciting muscular contraction, and the 
leg of a frog steeped in a solution of opium, or of hydrocyanic acid, is 
similarly affected. The same effect is produced upon the heart by infu- 
sions of opium and tobacco ; on the intestines by opium and ticunas ; on 
the iris by extract of belladonna ; on the hands by the handling of lead ; 
on the lips and tongue by chewing monkshood ; and on the ringers by 
the vapours of strong hydrocyanic acid. 

427. Narcotic poisons introduced directly into the circulation, or in- 
directly through the stomach or other circuitous channel, also act locally 
on the nerves. Thus, MiiUer, having divided all the vessels and muscles 
of the thigh of a frog, poisoned the animal with nux vomica, and found 
that the irritability of the sound leg was lost much sooner than that of 
the mutilated one. This loss of irritability in the sound leg can only be 
explained by the circulation through it of blood containing the poison, 
and the consequent local effect of the poison on its nerves ; and it is 
doubtless by such local effect on the parts of the nervous system most 
essential to life, or on the nerves supplying the heart or lungs that nar- 
cotic poisons, after being absorbed and circulated with the blood, prove 
fatal. 

428. It has also been proved that poisons act with greater force 
through the circulation than when applied directly to the nervous trunks. 
Thus, strychnia applied in powder to the moist spinal cord of the frog- 
excites no twichings of the muscles, while the most violent contractions 
are produced by very small quantities absorbed into the blood. Other 
experiments may be adduced to prove that poisons circulating with the 
blood produce their effect chiefly by acting on the spinal cord and brain. 
Thus, when an animal is poisoned by strychnia, if the nerves of one limb 
are divided, the spasms in that limb cease ; and if the spinal marrow is 
cut through before an animal is poisoned with upas, the parts supplied 
by nerves from the lower portion of the cord are not convulsed. 
Narcotic poisons generated within the body itself also act on the nervous 
centres through the circulation. Thus, urea, w T hen it accumulates in 
the blood from loss of power in the kidneys to eliminate it, acts on the 
brain, and causes fatal coma. 

429. The foregoing observations apply chiefly to the nerves of sensa- 
tion and voluntary motion, which have the brain and certain portions of 
the spinal cord for their origin and centre. The sympathetic nerve and 
the excito-motory system yet remain to be examined. 

430. The Sympathetic. — The functions of this nerve are threefold : 
it presides over the involuntary muscular fibre ; it is the medium by 
which all impressions are conveyed from the parts to which it is dis- 
tributed to the nervous centres ; and it regulates the processes of secre- 
tion and nutrition in every part of the frame. 



94 PHYSIOLOGY ABB GENERAL PATHOLOGY. 

431. With regard to the first of these functions — that of directing 
the involuntary motions of the more important viscera — it has been 
ascertained that the parts which this nerve supplies continue to move 
long after they aie separated from the rest of the sympathetic system, 
and even after their removal from the body, whether the motions are 
rhythmic, as in the heart, or continuous, as in the intestines : and that 
the contractility of these parts survives that of the voluntary muscles. 
The effects of stimuli applied to the sympathetic nerve are also more per- 
manent than those of stimuli applied to the nerves of voluntary motion. 

432. All the parts supplied by the sympathetic nerve are, to a certain 
extent, independent of the brain and spinal cord. Thus, the heart will 
continue to beat long after the division of its nerves, after severe injury 
of the brain and spinal cord, and even after its entire removal from the 
body. That the spinal cord, however, does influence the contractions of 
the heart has been proved experimentally ; and that the brain acts 
upon them is shown by the familiar effect of mental emotions. Certain 
excitations of the brain and spinal cord are doubtless conveyed to the 
sympathetic by means of the rami inter commv.rdc rates existing between 
the two systems of nerves, and by the same channels impressions on the 
sympathetic may be conveyed to the spinal cord and brain, and excite 
either sensation or movement in parts to which the cerebro-spinal nerves 
are distributed. 

433. The impressions made on the fibres of the sympathetic are not 
usually conveyed, to the brain ; in other words, they ai e not of the 
nature of sensations; but violent irritation may give rise to sensa- 
tion in parts supplied by nerves from the sympathetic as well as in those 
supplied by cerebro-spinal nerves. When these last-named nerves are 
the seat of the irritation, the painful sensations are usually experienced 
in the extreme parts of the organs which they supply : thus we have 
itching of the nose and anus from worms in the intestines, and pain and 
itching in the glans penis from disease of the kidneys and bladder. 
But irritation in the intestines, or a disordered condition of the uterine 
functions, is a familiar cause of reflected sensations of a still more 
marked character, such as acute pains in the muscles of the chest and 
abdomen in hysterical females, accompanied by tenderness of the spine 
itself, and sometimes removed by remedies applied to that part. 

434. The same irritation conveyed to the spinal marrow, and accom- 
panied by tenderness there, may also be reflected through the motor 
nerves, and give rise to spasmodic seizures. Thus, intestinal irritation 
occasions convulsions, chorea, and tetanus, in infants and young children, 
and hysteria affecting the muscles of voluntary motion, but especially 
those of respiration, in adults. Vomiting and hiccough are also pro- 
duced by irritation of the nerves of the intestines, kidneys, or uterus. 

435. The sympathetic nerve has been shown to preside over secretion 
and nutrition, and consequently over the functions of the parts con- 
cerned in these processes: the minute vessels, therefore, and the arterial 
system generally, fall under its influence. Section of the sympathetic 






SYMPATHIES. 95 

on one side of the neck causes permanent dilatation of the capillaries of 
the corresponding side of the face, and on irritating the trunk of the 
nerve they again contract. But although the organs of circulation are 
thus placed directly under the influence of the sympathetic, the occur- 
rence of syncope and blushing through mental emotion proves that 
impressions on sentient nerves may be reflected on the parts which it 
supplies. These reciprocal phenomena are due to the interchange of fibres 
between the two systems of nerves. The alteration in the size of the 
capillaries under the influence of emotion and in inflammation has been 
already adverted to (§ 272, et seq.). 

Such being the functions of the sympathetic, it follows that the cir- 
culation, both general and lccal, must be closely dependent upon the 
condition of this nerve. It is probable that the various states of circu- 
lation indicated by a pulse, ranging between a sharp, hard, and excited 
beat on the one hand, and a full, weak, compressible one on the other, 
are due to variations in nervous force transmitted by the sympathetic to 
the muscular tissue of the heart and arteries. It is also probable that 
the dilatation of the small vessels in inflammation is due to diminished 
nervous power in the sympathetic. 

436. In the general, as in the local affection, we may have first the 
application of a stimulus, accompanied by inciease of nervous force and 
consequent contraction of vessels, and then, as a necessary consequence, 
diminished nervous force, and relaxation of vessels. This contraction of 
the vessels is not overcome by a reaction in the centre of the circulating- 
system, but yields to that diminished contractility which follows as cer- 
tainly upon increased action as blunted sensibility upon over-exertion of 
the organs of sense, and fatigue upon long-continued or violent action of 
the muscles. This contracted state of the vessels is the spasm which 
plays so prominent a part in Cullen's theory of fever. 

437. The sympathetic nerve, as the name implies, is assumed to be 
the organ of many of those combined sensations, motions, and secretions 
which we call sympathies, by which we mean the reflection of impres- 
sions from one part of the nervous system to another and different part. 
It may be otherwise defined as reciprocal feeling or action between dif- 
ferent nerves, and therefore between different parts, caused by reflex 
nervous action. The nerves of the surface and the central organs of the 
nervous system, for instance, react on each other ; the affection of the 
central organs in fever causing the various conditions of the skin, and 
shocks to the skin, exciting the brain and spinal cord. Again, cold water 
poured on the head restores the brain exhausted by long-continued in- 
flammation ; and dashed in the face or thrown on the chest, removes an 
hysterical or fainting fit, excites the nervous centres in cases of narcotic 
poisoning, and is the most efficacious of remedies in asphyxia. 

438. Sensitive nerves sympathise with sensitive, motor with motor, 
and sensitive and motor with each other. The optic, the olfactory, the 
auditory, and the ciliary nerves of the two sides are affected at the same 
time and in the same wav, and an affection of one side often leads to a 



96 



PHYSIOLOGY AXD GENERAL PATHOLOGY. 



.similar affection of the other: inflammation of one eye to inflammation 
of the other ; deafness of one ear to deafness of the other ; an alteration 
in one pupil to a similar alteration in the other. This sympathy 
between nerves of sensation supplying double organs extends also to 
nerves of different kinds and functions : thus, a strong li^ht on the eye 
produces tickling in the nose ; tickling the feet throws the whole body 
into convulsions ; certain sounds put the teeth on edge ; a tumour on a 
nerve may cause pain or spasms in parts of the body in no way connected 
with it. To such phenomena the term radldion of sensations has been 
applied. Sympathies of motor nerves with each other occur in all 
associated movements; ihose of motor with sensitive nerves belong to 
the class of excited or reflected motions. 

439. The sympathies of entire organs with each other are very im- 
portant. They may be classed as follows: — 1. Sympathies between 
organs having similar structure and function ; as the different salivary 
glands, the heart and blood-vessels, the stomach and intestines. 2. Sym- 
pathies between organs belonging to the same system: as the digestive, 
the urinary, the generative, the respiratory system, and the united 
respiratory and circulating system, the lungs and heart. Thus vomiting 
attends the passage of a gallstone into the intestines. 3. Sympathies of 
important viscera with the central organs of the nervous system : as in 
the convulsions from teething, or intestinal irritation ; the sick head- 
ache, caused by the presence of indigestible food in the stomach; and, 
conversely, the affections of the stomach resulting from irritation or 
concussion of the brain. Epileptic fits often have their source in irrita- 
tion of the stomach, uterus, &e. 4. Sympathies between organs not 
connected in any of the foregoing ways : such as the parotid gland with 
the testicle ; the mamma with the uterus ; the larynx, and the glands 
which secrete the hair, with the parts of generation. To this class, too, 
belong the sickness attending the passage of a renal calculus into the 
bladder, the passing of a catheter, cr the pain of acute orchitis. 

440. The excito-rnotory system. The following plan will exhibit the 
extent and importance of this system : — 



Incident branches. 

I. Trifacial, arising from 

a. The eye-lashes. 

b. The alas nasi. 

c. The nostrils. 

d. The fauces. 

e. The face. 

II. Pneumo-gastricfrom 

a. The oesophagus and 

stomach. 

b. The mucous mem- 

brane of larynx. 

c. The bronchia 

d. The heart, kidney, 

and liver. 



Refiex motor branches. 



oculi. 



The trochlears ) 
The abducens / 



Minor portion of the fifth. 

Ohicularis 
Levator alas nasi 



( from 
-> the 
( facial. 

The pharyngeal plexus. 

The inferior laryngeal. 

The bronchial, kc. 

The oesophageal and car- 
diac. 



Excited actions. 

\ Protective movements of 
the eyes and eyelids. 
Of the iris ? 

Facial respiratory 
movements. Sneezing, 
laughing, &c. 

Suction and deglutition. 

, Closure of glottis, &c. 

Motions of air-passages 
in re.>-piration. 
j Motions of gullet and 
! stomach. 



I 



EXCITO-MOTORY SYSTEM. 



97 



Incident branches. 

III. Glosso - pharyngeal, 

from base of 
tongue and mem- 
brane of pharynx. 

IV. Posterior spinal from 

a. The general surface. 

b. The glans penis and 

clitoridis. 

c. The anus. 

d. The cervix vesicae. 

e. The cervix uteri. 



Reflex motor branches. 

The pharyngeal plexus of 
the Pneumo-gastric. 



The spinal accessory. 

Diaphragmatic, *} from 
Intercostal, > the 
Abdominal, ) spinal. 
The sphincters, | 
expulsors, eja- 1 from 
culators, Fal- > the 
lopian tubes, J sacral, 
uterus, &c. J 



Excited actions 

Associated movements 
of tongue and pharynx 
in deglutition. 



Movements of muscles 
of respiration. 

Expulsion of faeces, 
urine, and semen ; and 
of the fcetus. 

Retentive movements of 
sphincters— of the car- 
dia, of the valvula coli ? 
of the anus, bladder, 
neck of uterus? and 
vesicular seminales ? 



Tone and irritability of the muscular system. 

This table is compiled from data contained in Marshall Hall's work 
' On the Diseases and Derangements of the Nervous System,' the excited 
actions being placed opposite to those divisions of the first two columns 
with which they are most obviously connected. The excited actions in 
the third column are not produced by irritation of the incident nerves of 
the first, but correspond more closely with the action of the reflex motor 
branches of the second. Thus, the incident excitor branches of the nos- 
trils, when irritated, give rise not merely to the facial respiratory move- 
ments, but also to violent action of the muscles of respiration ; and irri- 
tation of the bronchial incident nerves excites not only the muscular 
fibres of the bronchial tubes, but the muscles of expiration also, to the 
act of coughing. 

441. The following table presents the pathology of the true spinal 
system ; also in accordance with the views of Marshall Hall : — 

PATHOLOGY OF THE TRUE SPINAL SYSTEM. 

Diseases of the Incident Nerves. 

1. Crowing inspiration. 

2. Strabismus, spasm of fingers and toes, 
strangury, tenesmus, &c. 

3. Convulsions. 

4. Paralysis. 

1. Hysteria. 

2. Asthma. 

3. Vomiting, hiccough, &c. 

4. Epilepsy. 

5. Puerperal convulsions, &c. 

aumatic tetanus. 
Hydrophobia, &c. 



I. Dental, Gastric, and Intes- 
tinal Irritation in Infants. 



II. Gastric, Intestinal, and Ute- 
rine Irritation in Adults. 



III. Irritation of textures sup- 
plied with nerves of com- 
mon sensation. 



1 1. Tra 
f 2. Hy. 



Diseases of the Reflex or Motor Nerves. 
Spasm. II. Paralysis. 

a. Spasmodic tic. 

b. Torticollis. 

c. Contracted limbs, &c. 



98 PHYSIOLOGY AND GENERAL PATHOLOGY. 

Diseases of the Spinal Marrow itself. 

I. Inflammation and other disease?. 
II. Diseases of the vertebrae and membranes. 

III. Counter Pressure, &c, in diseases within the cranium. 

IV. Centric epilepsy, tetanus, &c. 

V. Convulsions from loss of blood, &c. 

442. As we have seen, the condition of the nervous system and that 
of other functions of the body reciprocally affect each other ; but this 
mutual dependence is so strikingly displayed in the case of the circula- 
tion as to merit further consideration. 

443. The effect of the emotions and passions, and of all violent exer- 
tions of the body, on the heart, is a matter of daily observation ; and so 
surely does the circulation participate in every change of the nervous 
system that it becomes the best test of its degree and amount. Every 
violent exertion of different muscles, and every long-continued exercise of 
the same muscles, strongly excites the pulse ; and rest not only restores 
the number which it had before the effort, but for a time still further 
reduces it. The various causes of excitement to which we are exposed 
during our waking hours affect the circulation in the same way ; and it 
is the fatigue thus produced that causes the pulse to fan towards even- 
ing, to regain its frequency when the body has been refreshed by sleep. 
Precisely the same effects are produced by disease. Thus, in febrile affec- 
tions the pulse during the height of the disorder is much more frequent 
than in health, but during convalescence the pulse falls many beats be- 
low its natural frequency, to regain it as health and strength return. 

444. Another remarkable fact established by careful observation of 
the pulse is, that it is much more affected by all causes of excitement 
when we are in full possession of our strength, than when exhausted by 
fatigue. Thus all stimuli — muscular exertion, food, drink, and even 
mental application — have a much greater and more enduring effect on 
the circulation in the morning than at night. 

445. But there are states of debility in which the heart's action is 
more frequent than in health. This occurs in an advanced stage of con- 
valescence, when the patient begins to recover strength, and also in the 
decline of febrile affections, so long as any degree of fever continues. A 
greater degree of debility in the absence of actual disease is characterised 
by a very small and very frequent pulse; but such debility is rare, 
except as the consequence of diminution in the quantity of the blood, 
whether from haemorrhage or from excessive discharges. 

446. When nervous exhaustion is accompanied by local disease, 
whether functional or structural, that state or' system exists to which 
we give the name of irritation. It occurs in slow convalescence from 
fever, when some local affection supervenes ; as an immediate consequence 
of severe injuries in subjects weakened by disease or bad habits of life; 
and as a more romote consequence in sound constitutions, the injury 
itself producing in these the same nervous exhaustion which bad habits 
or previous disease had occasioned in those. 



IRRITATION. 99 

447. Another example of the action of the nervous system on the 
circulation is afforded by that temporary arrest of the heart's action 
known as syncope, or fainting, brought about, as it may be, either by 
violent shocks, originating from without, as in accidents, or from within, 
as in violent emotions. Sometimes the heart is paralysed by the shock, 
and death results. 

448. The movements of the heart partly depend on the pneumo- 
gastric nerve ; hence, when the functions of the centre in which this 
nerve originates are interfered with by cerebral effusions, by injury of 
the medulla oblongata, or by the circulation of impure blood, the force 
and number of the heart's contractions are diminished. 

449. The effect produced on the nervous centres by changes in the 
circulation is more important even than those which the circulation 
suffers by alterations in the state of the nervous system. The exhaustion 
which follows strong nervous excitement has its counterpart in that pro- 
duced by loss of blood, which causes syncope or death, partly by depriving 
the heart of its stimulus, and partly by paralysing the nervous centres. 

450. In healthy persons loss of blood occasions debility proportioned 
to the quantity lost ; but in persons afflicted with local disease, or of a 
broken constitution, the debility reinforced by nervous excitement becomes 
irritation. The same effect follows when the quantity of the circulating 
fluid is diminished by profuse discharges, such as leucorrhcea or diarrhoea, 
or by the excessive and continued drain of natural secretions, as in me- 
norrhagia, and in prolonged suckling. But the puerperal state, com- 
bining, as it does, nervous exhaustion, loss of blood, a local affection, 
and a sudden change of the equilibrium of the fluids, presents the most 
vivid picture of this state of irritation. 

451. In this condition of irritation, as in that originating in the ner- 
vous centres themselves, the circulation is affected, and we have the 
frequent quick pulse easily excited by mental emotion or by strong and 
sudden impressions on the organs of sense. The functions of the brain 
also suffer ; and we have, according to the degree of irritation, mental 
excitement, delirium, or mania. The nervous influence conveyed to the 
muscular system betrays the same derangement by restlessness, jactita- 
tion, convulsions, and spasms in the voluntary muscles, and frequent or 
irregular breathing, laughing, crying, sighing, sobbing, and yawning, 
in those of respiration. The nerves of sensation also participate in the 
general derangement, and we have intolerance of light and sound, ex- 
cessive sensibility of surface, and acute reflected pains in the walls of the 
chest and abdomen. The stomach likewise shows its sympathy with 
the nervous centres by nausea, vomiting, or hiccough. 

452. Such are the phenomena of the state of irritation, whether 
originating in the nervous system, or in the circulation. It is a state 
aggravated by depletion, but relieved by remedies that impart strength 
while they soothe excitement. A combination of narcotics and tonics, 
or, if the debility is extreme and the nervous symptoms urgent, of nar- 
cotics and stimulants, is the remedy indicated. 



100 PHYSIOLOGY AXD GENERAL PATHOLOGY. 

453. The influence of the nervous system over muscular movements 
has already been alluded to, and two classes of movements have been 
described, the involuntary and the voluntary ; the former excited by 
changes in the condition of the incident or excitor nerves entailing cor- 
responding changes in the reflex or motor nerves, and the latter by the 
will. In disease, or in peculiar states of system, the one set of muscles 
takes on the character of the other, the involuntary muscles obeying 
voluntary impulses, and the voluntary muscles performing involuntary 
contractions. 

454. A well-authenticated example of involuntary muscle being sub- 
ject to the will occurred in the case of a Colonel Townsend, who possessed 
the strange faculty of stopping the beat of his heart at will. The same 
power seems to have existed in one or two other instances. 

455. The most striking examples of involuntary actions of voluntary 
muscles observed in disease are, chorea, hysteria, epilepsy, catalepsy, 
convulsions, tetanus, hydrophobia. Of these diseases some depend on 
the direct influence of the nervous centres, but the greater part are ex- 
amples of a reflex action. 

456. When the contractions continue in the same muscles for a cer- 
tain space of time, producing a state of continuous rigidity, they are 
said to be tonic ; w^hen the muscles are alternately contracted and re- 
laxed, they are called clonic. Tetanus, hydrophobia, and catalepsy are 
examples of tonic spasm ; chorea, hysteria, epilepsy, and convulsions 
(unless the term is qualified by such words as rigid or tetanic) are cases 
of clonic spasm. 

457. In chorea and hysteria, voluntary and involuntary impulses are 
strangely blended ; but the will exercises a different degree of control 
in the two cases. When the patient in chorea wills a movement, the 
involuntary action, mixing with the voluntary effort, causes grotesque 
distortions, which attempts at restraint only increase ; but the move- 
ments of the hysteric patient are less grotesque, though more violent, 
and can often be restrained by a strong effort of the will. 

458. Convulsions are examples of unmixed involuntary contraction, 
commonly due to reflex action ; but when they follow the loss of blood, 
they probably arise from the sudden removal of that nervous influence 
which maintains the tone and equilibrium of the muscles. Hence the 
flexors, which are the stronger muscles, contract, and the extensors, being 
put on the stretch, are in their turn Drought into action, and thus an 
alternate or clonic contraction of the two sets of muscles takes place ; but 
the flexors at length overpower the extensors, and if death ensue, the 
fingers and toes aie found flexed. 

459. Convulsions, then, are often the last movements of a living 
body. They are also most efficient means of recovery, for when the cir- 
culation has nearly ceased, and the heart does not receive blood enough 
to excite it to action, the contraction of the muscles of the limbs forces 
the venous blood towards the heart, and thus tends to re-establish the 






ANIMAL HEAT. 101 

circulation. The trembling of the limbs fiom cold (a low degree of 
convulsion) has the same beneficial effect in restoring the circulation. 

460. The nerves of sensation, like those of voluntary motion, are 
subject to various derangements. Sensation may be lost (anaesthesia), 
or exalted (hyperesthesia;, or perverted (noseraesthesia). The loss of 
sensation which sometimes accompanies palsy is an example of anaesthesia 
affecting the nerves of touch ; and amaurosis, of anaesthesia of the optic 
nerve. Intolerance of light and sound, and violent hunger and thirst, 
are examples of hyperaesthesia. The strange pains and anomalous sensa- 
tions of hysteria and hypochondriasis, are instances of noseraesthesia. In 
some hysteric females there seems to be diminished sensibility of the 
nerves of touch, with increased sensibility of other nerves, the sensibility 
appearing to be withdrawn from the one to be concentrated in the other. 
Hence some of the strongest phenomena of nervous affections, including 
those induced by the manipulations of the mesmeriser. 

461. There still remain to be considered two functions closely de- 
pendent upon the nerves, though connected more or less with the changes 
which are constantly taking place in the fluids and textures of the 
frame : — the generation of heat and electricity. 

462. Animal Heat. — The cause of animal heat is still a subject of 
controversy ; but the experiments of Depretz and Dulong, as interpreted 
by Liebig, have rendered it highly probable that animal heat is entirely 
due to the combination of the carbon and hydrogen of the blood with 
the oxygen of the air. This combination, formerly supposed to take 
place in the lungs, is now believed to occur in the minute structures of 
every part of the system by means of the oxygen absorbed in exchange 
for the carbonic acid expelled from the lungs. It has also been shown 
experimentally that the nerves influence the temperature of the body. 
Though the precise effect of each of these causes in the production of 
animal heat has not yet been determined, observation has shown that its 
amount varies greatly in different states of the system. 

463. The temperature of those internal parts which are most acces- 
sible — viz., the mouth and rectum — is about 97|° or 98^-° Fahr. T hat 
of the external parts is somewhat lower, and it has been observed to differ 
in parts near to and remote from the centre of the circulation ; thus, 
Dr. J. Davy observed, that the temperature of the axilla being 98° F., 
that of the loins was 96 J°, that of the thigh 94°, that of the leg 93° to 
91°, and that of the sole of the foot 90°. The temperature of the blood 
was about 101°. 

464. In disease remarkable deviations from the standard temperature 
have been observed, both in excess and in defect. In inflamed parts it 
has been found as high as 105° or 107°, and the heat of the whole 
surface has reached the same degree in some cases of fever, and risen 
still higher (to 112°) in scarlatina. On the other hand, in morbus 
caeruleus and in the cholera, the temperature has been observed as low 
as 77A° or 77°. 



102 PHYSIOLOGY AXD GENERAL PATHOLOGY. 

465. In most diseases the temperature bears a pretty exact proportion 
to the pulse ; but remarkable exceptions to this rule have been observed, 
and notably in cases of fever. Thus, in fever a pulse of 45 has coin- 
cided with a temperature of 105° ; and in hydrocephalus a pulse of 60 
or 70, with a temperature of 100°. 

466. Electricity. — The facts ascertained with regard to free electri- 
city in man are the following: — As a general rule the electricity is 
positive, but in the female more frequently negative than in the male ; 
it is more abundant in persons of a sanguine than in those of a lymphatic 
temperament; greater in the evening than in the morning; greater 
when the temperature of the body is high than when it is low : it is in- 
creased by spirituous liquors, and reduced to zero in rheumatic affections. 
The free electricity of the body is generally of very feeble intensity ; but 
in peculiar states of system sparks have been given out in great abun- 
dance. There exists in the nerves of all animals, independent of all 
mechanical and chemical actions in the body or external to it, a natural 
electricity, circulating in closed currents from the central parts of the 
nerve fibres which are in a — condition, to the surface which is in a -f- 
state. There is, in fact, an electrical antagonism between the transverse 
and vertical sections of the nerve. The same phenomena are presented 
in muscular fibres, but they are no doubt due to the nerves contained 
within them. 

5. MENTAL PHYSIOLOGY AXD PATHOLOGY. 

467. Some of the most difficult and responsible duties which the 
physician is called on to perform have relation to the mind. Mental 
disorders more or less permanent, and more or less dependent on bodily 
diseases, are of common occurrence in the practice of all physicians ; and 
they engage the exclusive attention of a considerable body of medical 
practitioners. Hence the physiology and pathology of the mind have 
claims on the attention of the medical man second only to those advanced 
by the physiology and pathology of the material structures. 

468. Indeed the brain, the mind's instrument, built up and nourished 
as other structures are, de living its supply of blood from the same 
centre, through the same intricate network of arteries and veins, is 
affected by every change in the composition of the blood, and in the 
balance of the circulation ; and is subject to like functional and struc- 
tural diseases with other 0;gans of the body. 

469. The brain and nervous system, as pirts of the material fabric 
of the body, must also be subject to all the influences, external and 
internal, already examined (§§ 4 to 88). Between brain and brain, as 
between body and body, it is reasonable to expect important original and 
acquired differences: original differences in size, shape and consistency, 
and others more difficult to define, resulting from temperament, diathesis, 
and idiosyncrasy, from age. sex, and race; and acquired differences, due 
to climate, residence in town or country, education, occupation, and 
habits of life. 



THE ORGANS OF SENSE. 103 

470. Many of these physical agents act on the brain and nervous 
system more promptly and forcibly than on any other part of the body. 
This is especially true of excitement, fatigue, dissipation, intemperance, 
and inaction. Many poisonous agents, too, take effect chiefly on the 
brain and nervous system, and prove fatal by the functional disturbance 
to which they give rise. 

471. Again, the brain, as the mind's material instrument, is subject 
to inaction, to wholesome exercise, or to over-exertion, according as 
education is neglected or enfo ced in early life, and in proportion to the 
necessity which exists for self-culture and labour in after life. 

472. If, then, we consider the brain from this twofold point of view 
(as a constituent part of the body, subject to all the influences by which 
it is affectel, and as the material organ of the mind developed by mental 
exercise,, we shall be prepared to find the differences between mind and 
mind, in health and disease, equalling and even surpassing those already 
pointed out (_§ 88 ; as existing between body and body. 

473. The brain, as already stated (§ 408), is the centre both of 
intelligence and of action, to which all sensations are referred, and from 
which all volitions emanate. It performs these functions subject to the 
condition that the nervous communication in both directions (inwards from 
the organ of sense, and outwards to the muscles) shall be unbroken. 

474. Each organ of sense consists of three parts: 1, an external ap- 
paratus on which the impression of the object is made by contact, as in 
the senses of touch, taste, and smell, or by intermediate undulations or 
■vibrations, as in the senses of sight and hearing ; 2, a nerve transmitting 
this impression to the brain ; and, 3, a portion of the brain itself set 
apart, as is probable, for taking cognizance of the impression thus pro- 
duced and conveyed ; and (as in the case of the two eyes) combining two 
distinct impressions into a single sensation. Each distinct apparatus of voli- 
tion, such as the organs of speech and of locomotion, consists, in all pro- 
bability, of similar constituent parts; 1, of a portion of brain in which 
the act of volition originates ; 2, of a nerve or nerves by which the 
mandate is conveyed ; and, 3, of a group of muscles by which the man- 
date thus originated and thus transmitted is obeyed. 

475. The parts of the brain to which the several sensations are con- 
veyed, and from which the mandates of the will issue, are subject both to 
original deficiency and to the disabling effects of disease. £ome persons, for 
instance, are unable to distinguish colours, others to recognise musical 
notes and intervals ; and, on the other hand, a few, with perfect hearing 
and well-formed organs of speech, have never been able to articulate. 
Blindness from disease of the parts of the brain to which the optic nerves 
join themselves, and loss of speech from apoplexy affecting the base near 
the origin of the lingual nerves, are familiar examples of the disabling 
consequences of disease. 

476. In tracing the path of sensation from without to within — from 
the impression on the organ of sense to the part of the brain that takes 



104 PHYSIOLOGY AXD GENERAL PATHOLOGY. 

cognizance of it — we come in contact, so to speak, with two important 
operations, or faculties, of the mind, volition and memory. 

477. Volition plays an important part, not merely in directing all 
those muscular movements by which we provide for our subsistence 
and communicate with our fellows, but also in perfecting the work of 
sensation begun by the organs of sense. Without that act of volition, 
which, w r hen brought to bear on our sensations, constitutes attention, 
no external object could be either distinctly pe ceived, or recollected. 
On the other hand, without that power of reproducing sensations which 
constitutes memory, the more complicated acts of volition could have no 
existence. Hence, volition and memory would appear to be closely linked 
together, to have their material instruments nearly connected in certain 
parts of the brain, and to be subject to be simultaneously impaired by 
disease. But the will and memory are not limited in their operations to 
muscular movements and bodily sensations ; for the will also directs and 
controls the operations of the mind, and the memoiy stores up and repro- 
duces not sensations only, but trains of thought, processes of reasoning, 
complicated transactions, and the workings of emotion and passion. 

478. It has just been stated that impressions made on the senses, in 
order that the mind may take cognizance of them, must be accompanied 
by an act of volition known as attention. Now, whenever an object of 
sense is also an object of attention, it is said to be perceived ; in other 
words, sensation becomes perception. 

479. Perceptions vary greatly in intensity in different persons, at 
different ages, and in different states of body ; and the same difference 
exists in regard to that reproduction of perceptions which constitutes 
memory or recollection. In some persons, perceptions are reproduced 
with extraordinary quickness, vividness, and fidelity, while in others 
they can scarcely be reproduced at all ; and one of the principal features 
of the mind in old age, and of the unsoundness of mind peculiar to the 
aged, consists in the obtuseness of the perceptions, and the extraordinary 
difficulty with which they are recalled or reproduced. Perception and 
memoiy, indeed, bear a pretty exact relation the one to the other. The 
objects best perceived are best remembered, and those that made scarcely 
any impression on the senses are not reproduced at all, or with great 
indistinctness. 

480. In a few individuals, perceptions are reproduced with such vivid- 
ness and fidelity that objects formerly perceived, are, so to speak, painted 
on the retina, or transferred to the other organs of sease by an effort 
from within. This perfect operation of memory, this power of depicting 
objects on the retina by the force of thought, is sometimes attributed to 
the imagination, and is termed conception. The poet Goethe had it 
during the whole of his life ; and in a few instances, the same power is 
retained during childhood. 

481. When this transference of thought to the organ of sense is invo- 
luntary, it constitutes illusion, of which the most familiar form is spectral 
illusion. 






ATTENTION — ABSTRACT REASONING — ASSOCIATION. 105 

482. Objects of sense, then, make impressions which vary in intensity 
with the degree of attention bestowed upon them. When the mind is 
preoccupied by thought, objects presented to the. senses make little or no 
impression, and are neither observed nor remembered; and this pre- 
occupation, or absence of mind, explains the eccentric acts of absent men, 
and some of the unaccountable proceedings of madmen. 

483. By that effort of the will, then, which we call attention, we are 
able to perceive objects with more distinctness, and to reproduce percep- 
tions with more facility. Now, sensations do not come into the mind 
singly, but in groups ; and our knowledge and expeiience of the objects 
that surround us are compounded of many sensations. Thus, an orange 
produces a sensation of size, of shape, of colour, of weight, of odour, of 
taste; and it is by an effort of the will alone, in other words, by an 
effort of attention, that we single out one of these sensations which the 
word orange represents, and make it a separate subject of contemplation. 
This separation of one sensation from another is called abstraction, and 
the exercise of the mind upon sensations thus separated is called abstract 
reasoning. 

484. This power of abstraction is the more necessary as it is needed 
to control and correct a directly opposite faculty, or mode of action, 
of the mind — the faculty of association. As attention separates and 
isolates sensations which are commonly combined, so does association 
combine, and cause to reappear together, or in rapid succession, those 
sensations or ideas which either took place simultaneously or successively, 
or which have in any way been previously conjoined. 

485. This tendency of sensations and ideas to reappear in the con- 
nection or succession in which they had previously entered the mind, 
can be broken through only by an effort of the will ; but when such 
effort has repeatedly placed in combination or succession a number of 
sensations or ideas, this very combination or succession, though originally 
forced and voluntary, soon submits to the law of association, and a fresh 
effort is necessary to separate and disarrange them. 

486. That repetition of sensations, thoughts, or movements, at first 
distinct, difficult, and voluntary, which at last transfers them from the 
dominion of attention to that of association, is called habit, of which, 
when this transference is complete, a man is said to become the slave. 

487. By a faculty allied to, if not identical with, this of association, 
the mind also passes from one thought or recollection of an agreeable or 
of a painful character, to another of the same complexion. 

488. Attention directed to different sensations or ideas in alternation 
or succession implies a faculty of comparison ; which faculty, in a being 
possessed of free will, implies also a power of choice. 

489. This faculty of comparison is essential to the acquisition of 
knowledge, as well as to the regulation of our actions. The impressions 
made on one sense must be compared w 7 ith those made on another, the 



103 PHYSIOLOGY AND GENERAL PATHOLOGY. 

eye must correct the ear, and the sense of touch the eye, in order that 
we may form distinct and precise notions of the properties of external 
objects. The sensations or ideas reproduced by the memory must also 
be contrasted with those caused by objects present to the senses. In the 
unsound mind, this power of comparison is lost, and intrusive memories 
or passing fancies are taken for realities. 

490. Without the exercise of this faculty of comparison it would be 
impossible to make a single step in art or science. Orderly arrangement 
and scientific classification are wholly dependent upon it. 

491. The objects grouped by the aid of this faculty are either the 
same or similar ; that is to say, all their properties agree or only some. 
Hence, we are able to say of anyone object contained in a group or class 
what we are able to say of every other, either in respect of all its pro- 
perties, or of that one property which formed the basis of the classifica- 
tion. Xow this twofold process of constructing groups of individuals, 
and then affirming of the individuals that they possess the property or 
properties which first led to their being thrown into groups, is the secret 
of all our knowledge — of science in its highest and in its lowest forms. 

492. When the objects thus grouped are simple in themselves and 
exactly alike, and when the words used to describe or define them can 
be understood only in one sense, our knowledge is absolutely certain : 
but when they are complex and only similar, and our words less precise, 
we are obliged to content ourselves with knowledge less definite and 
exact. Now, there is only one class of objects to which the first part of 
this description applies, and these objects are mere abstractions ; that is 
to say, they consist of the universal relations, as distinct from the special 
properties, of matter, such as space, time, number, position, direction ; 
with regard to which we can make assertions that can neither be doubted 
nor denied, and definitions that cannot be misunderstood : and Reason, 
availing herself of these assertions or axioms, and of these plain defini- 
tions, and using a language at once condensed and intelligible, has built 
up that vast and wonderful fabric of abstract knowledge known as the 
'mathematics. 

493. Every comparison of one object with another, or of one object 
with the group to which it belongs, results in an inference expressed or 
understood ; and these acts of comparison, with the inference drawn 
from them, constitute a process of reasoning. So that reason may be 
defined as the faculty by which we draw inferences from comparisons. 

494. Now every process of reasoning, however complicated it may 
seem, consists of two assertions, containing the elements of a comparison, 
and an inference. The first assertion is, that a group of objects possesses 
this or that property or properties ; the second, that an individual 
object belongs to that group ; and the inference is, that, as a necessary 
and inevitable consequence, this individual has the properties of the 
group to which it is asserted to belong. These two assertions are tech- 
nically called premisses (major and minor), and these, with the conclu- 
sion or inference, constitute the syllogism of the logician. 



FALLACIES IX SEASONING — IMAGINATION. 107 

495. It is of the first importance to understand that when fallacies 
creep into a process of reasoning, they are to he found in the premisses, 
from which the inference, or conclusion, is a necessary consequence : and 
this observation applies to the operations of the unsound, as well as of 
the sound mind. For there are forms of unsound mind in which the 
power of making just comparisons and drawing correct inferences is re- 
tained ; the defective reasoning consisting in erroneous premisses dictated 
by distorted perceptions, a perverted imagination, or over-excited feelings. 

496. In cases of monomania, or partial intellectual mama, when the 
patient believes that his fool is poisoned, or that his body has been 
changed from flesh and blood into glass or butter, this power of drawing 
just inferences from false principles is seen in action ; for such a patient 
will not merely reason correctly on the false and incredible assumption, 
but he will shape some at least of his actions in obedience to the inference 
correctly drawn from the false premiss. 

497. There are, however, other forms of mental unsoundness in which 
the reasoning faculty is so impaired, that even the formation of a simple 
syllogism is impossible. This happens in extieme cases of dementia and 
in the dementia of old age. Again, there are cases of idiocy, or of ex- 
treme imbecility, in which the reasoning faculty has never been developed, 
even to the extent of comprehending or employing the simplest and 
easiest arguments. There is also a condition of the unsound mind, cha- 
racterised by complete incoherence, when all the faculties are in a state 
of intense excitement and hurry, so that there is not. so to speak, breath- 
ing-time for the deliberate exercise of thought or reflection. 

498. Some account has now been given of those organs and faculties 
by which we obtain knowledge ; of the senses as its prime source ; of 
sensations, as the impress of outward objects on the sensorium ; of per- 
ceptions, as sensations recognised and strengthened by attention ; of 
conception, as sensations without corresponding outward objects, repro- 
duced by the intense operation of the mind itself ; of memory, as the 
faculty by which sensations are less distinctly reproduced ; of attention, 
as that by which sensations are strengthened, separated, or arbitrarily 
combined ; of association, as the faculty by which sensations are linked 
together in their original or acquired relations ; of comparison, as that 
by which sensations or ideas are contrasted ; and, lastly, of reason, as the 
faculty by which conclusions or inferences are drawn from premisses. 

499. By the aid of these faculties alone we might have accumulated 
knowledge, and created arts and sciences; have obtained much acquaint- 
ance with the properties of matter, and some mastery over it : and we 
might have made some advances in civilization. But without that in- 
ventive, suggestive, anticipating, exaggerating faculty which we call 
imagination or fancy, hypothesis, theory, poetry, and high art would 
have been impossible, and several forms of unsound intellect unknown. 

500. The province of this faculty would seem to be to select and 
arrange, in new and arbitrary combinations, forms, colours, sounds, de- 



108 PHYSIOLOGY AXD GENERAL PATHOLOGY. 

scriptive words and phrases, and even the simplest and most abstract 
facts of science, with a view to please, persuade, and amuse ; or, to 
speak more generally, to excite in the minds of others, by every kind of 
skilful combination and contrast, emotions pleasurable or painful. The 
most arbitrary of these combinations, when relating to matters of 
science, are termed hypotheses ; when employed upon trivial subjects, 
and directed to mere amusement, they are known as wit and humour. 
For practical purposes it may suffice to state that men exercise the ima- 
gination, or fancy, whenever, without intention to deceive, they make 
assertions incapable of proof, or unsupported by the concurrent testimony 
of other persons having the same opportunities of observation or expe- 
rience with themselves. 

501. Of the intellectual faculties, the imagination is that which has 
the strongest affinity with the emotions and passions, for its operations, 
like theirs, are attended by excitement. It seems, indeed, to hold a 
middle place between the intellect and the passions ; adding vigour and 
originality to thought, while it lends attraction to objects of desire, and 
gives intensity to every effort by which they can be compassed. 

502. The powers or faculties of sensation, perception, conception, 
comparison, reasoning, and imagination, make up the sum of what are 
commonly known as the intellectual faculties. They may all be said to 
be dependent, primarily, on the senses, and to subserve the work of con- 
templation ; but the faculties now to be considered lead direct to action. 
They are known as passions and emotions, as active and passive emotions, 
or as propensities and sentiments. 

503. Between emotions and passions it is not easy to draw an exact 
line of demarcation ; but it is usual to characterise benevolence, venera- 
tion, hope, fear, grief, remorse, as emotions ; lust, anger, ambition, 
vanity, as passions. Although there is undoubtedly a distinction between 
them, yet they resemble each other in this — that they arise in the mind 
spontaneously whenever the object calculated to excite them is presented 
to it, whether from without by the senses, or from within by the memory. 
They do not arise from any process of reasoning, or from any exercise ot 
comparison, but resemble instincts in the rapidity with which they spring 
up, the certainty with which they are directed to their objects, and the 
promptitude with which they act. When very strongly developed, or 
excited, they act even in persons of sound mind so quickly as to forestal 
the exercise of reason. Indeed reason, in the sense of the reasoning 
faculty, is in the very nature of things too slow in its movements to 
form an efficient check to passion, or a safe guide to emotion. To check 
the one and regulate the other is the work of conscience, an original and 
innate faculty, but one in some degree formed and moulded by instruc- 
tion communicated in early life, and modified by the habits of society. 
Acting with all the quickness and precision of an instinct, it is the only 
faculty prepared to oner effectual resistance to the feelings and passions. 

504. As the intellectual faculties exist both originally, and as a con- 
sequence of habit and culture, in very different proportions in different 



ILLUSIONS. 109 

persons, so also do the emotions and passions; and just as education 
gives acuteness to the perceptive and reasoning faculties, indulgence gives 
power to the emotions and passions, and restraint, on grounds of reason 
and right, supremacy to the conscience. 

505. This sketch of the mind in its sound state would be incomplete 
if some allusion were not made to those first truths in which all sane 
men believe, without any conscious operation of the intellect. These are 
a belief in our own personal identity ; in the real existence of objects of 
sense ; in the uniformity of the operations of nature ; and in the neces- 
sary connection of cause and effect. 

506. Having thus briefly considered the faculties by which we gain 
and impart knowledge, the emotions and passions which move us to 
action, the conscience which counsels and restrains, and the first truths 
without a belief in which life itself could scarcely be preserved; our 
attention will naturally be directed, in the next place, to certain states 
of the senses and of the mind, which, while they do not constitute mental 
unsoundness, often enter into that state as constituent parts, andjserve to 
throw valuable light upon it. 

507. The first of these conditions is illusion of the senses, among 
which spectral illusions are the most interesting. 

508. All the senses, without exception, may become the seats of ab- 
normal impressions — the eye of bright or dark spots, and circles of 
colours ; the ear of humming, hissing, or blowing sounds, or distinct 
musical notes ; the taste, of bitter, salt, or sour savours : the sense of 
smell, of unreal odours ; and the sense of touch, of a feeling of local 
pressure, of heat or cold, of creeping, itching, pricking, and tingling. 
These false sensations are due to changes in the circulation through the 
brain, or through the nerve of sense. 

509. Objects of sense are also apt to be exaggerated, or the reverse, 
by peculiar states of the organs of sense, or of the brain ; and especially 
during slight febrile attacks, or in the early stage of convalescence from 
febrile disorders. Visible objects grow to enormous dimensions, or 
dwindle to the smallest size ; and sounds seem lower or louder than 
they really are. 

510. Similar exaggerations often take place under the influence of 
strong mental emotion, especially fear. Good examples of this sort are 
supplied by two cases of theft. A stick of a certain length was given to 
a number of suspected persons with the assurance that the stick of the 
thief would grow by supernatural power. The culprit, imagining that 
his stick had actually increased in length, broke a piece off, and was thus 
detected. A farmer detected depredations on his corn-bin, by calling his 
men together, and making them mix up a quantity of feathers in a sieve, 
assuring them that the feathers 'would infallibly stick to the hair of the 
thief. After a short time one of the men raised his hand repeatedly to 
his head, and thus betrayed himself. 



110 PHYSIOLOGY AXD GENERAL PATHOLOGY. 

511. Another affection of the organs of sense allied to true spectral 
illusions, consists in an extraordinary permanence of impressions. One 
instance in which the notes of a bugle remained on the ear for nine 
months is mentioned by Abercrombie ; and another, in which the spec- 
trum of the sun remained on the retina for ten years, is cited by Feuch- 
tersleben from Boyle. 

512. Impressions made on the senses have also been reproduced with 
great exactness after an interval of time. When Dr. Ferrier was about 
fourteen years of age an interesting scene which he had witnessed during 
the day was reproduced with great fidelity, on entering a dark room, 
and continued visible for some minutes. In this instance the reproduc- 
tion seems to have been involuntary; but Goethe could produce pictures 
at will, though unable to dismiss them when he desired to do so. 

513. From pictures on the retina, conjured up by an effort of the 
will, without corresponding object present to the eye, and from similar 
pictures produced without effort through vivid impressions previously 
made, the transition is easy and natural to those illusions of the senses, 
and especially of the sense of sight, over which the individual affected by 
them has no control, and which have also no relation to objects previously 
perceived, Such illusions are of special interest, inasmuch as, though 
quite compatible with perfect sanity, they are very common in cases of 
unsound mind. 

514. Several interesting cases of ocular spectra, so closely resembling 
real objects as to be distinguished only by the most careful exercise of 
comparison and judgment, are recorded in Sir David Brewster's " Natu- 
ral Magic." and Sir Walter Scott's i; Demonology and Witchcraft." 
A lady, whose case is related by Sir David Brew T ster, had the sense of 
hearing first affected, her husband seeming to speak to her, though not 
near her. Illusions of the sense of sight followed. She saw spectres of 
her husband ; of a near relation in a shroud ; of a deceased friend ; and 
of a spectral cat. But whether the illusion was of the ear or the eye, 
the mind was quite aware of the real seat and nature of the deception. 

515. The woman in the red cloak, seen by Mr. Abernethy's patient, 
the ghastly spectre wdiich appeared to Lord Castlereagh at night, and 
the figurantes in green who drove Sir Walter Scott's young man of for- 
tune out of England, all belong to this class. 

516. Many remarkable men have been subject to these false impres- 
sions. The list comprises the names of Luther, Oliver Cromwell, 
Pascal, Goethe, Cellini, and Swedenborg. The student worn out by 
application, the religious enthusiast exhausted by watching and fasting, 
Silvio Pellico in his solitary confinement, the sailors of the ' Medusa ' 
suffering from mingled privation and excitement, the drunkard and the 
opium-eater, and persons under the influence of poisons of the narcotico- 
acrid class, have all afforded examples of spectral illusion. 

517. Spectral illusions, too, are not rare in females at or about the 
change of life, when suffering from the group of nervous symptoms so 



SPECTRAL ILLUSIONS. Ill 

common at that period (mimosis inquietd). In either sex, they may 
occur at any age from 4 to 80. 

51 8. Lastly, spectral illusions are common in dreams, in delirium, and 
in madness ; so common are they in this last condition, that Esquirol 
estimates at 80 per cent, the proportion of persons so afflicted, who are 
subject to illusions of one or other of the senses. 

519. Though illusions of the senses occur in persons both of sound 
and of unsound mind, they differ in this, that the madman believes in 
their reality, while the sane man soon learns their true character by the 
use of the other senses, or by some other effort of comparison. There 
are, indeed, two ways in which these false perceptions may be corrected : 
1, by confronting them with some real sensation, as in a case mentioned 
by Abercrombie, in which the lock of a door was seen through the spec- 
tral figure ; and 2, by a comparison with the perceptions of other 
persons, as in Mr. Abernethy's case of the woman in red. A blind 
patient of the Editor, though in no danger of misunderstanding the real 
nature of his illusions, was always struck with the circumstance that 
his figures moved about quite silently. The man of unsound mind 
neglects all these means of undeceiving himself, or is unable to use them ; 
or, if he entertain any doubt, he has some false reason to assign in favour 
of the reality of the supposed object of sense. A religious maniac, for 
instance, will think it impious to doubt. 

520. Spectral illusions can sometimes be traced to thoughts or wishes 
which had previously passed through the mind. A patient of the 
Editor, recovering from a slight attack of fever, preceded by a severe 
family affliction, slept, during the heat of summer, in a room command- 
ing a view of a large pond. One day he was seized with a great desire 
to bathe, and on the evening of that day a spectre appeared at his bed- 
side, drew aside the curtains, and invited him to the water. This fact 
is rendered the more interesting by the circumstance, that though the 
patient's mind was so far recovered as to allow of his reasoning calmly 
upon the occurrence, his mood of mind and expression of countenance 
changed in an instant, and he affirmed with great energy his determina- 

I tion to accompany the spectre should it appear to him again. A similar 
illustration of the occasional dependence of spectral illusions on the 

. natural workings of the mind was afforded by an old lady, also a patient 

•: of the Editor, who, on two occasions, under the apprehension of the fatal 
issue of severe attacks of illness in her children, saw the whole parapher- 

rnalia of a funeral cross her room. 

521. In some forms of unsound mind, especially in that known as in- 
coherence, it is probable that illusions succeed each other with a rapidity 
only to be compared with the hurry of the thoughts to which the patient 
gives utterance. 

522. Considerations of great interest and practical importance connect 
themselves with spectral illusions. — 1 . They are independent of the will ; 
for they form the very staple of dreams in which the will is suspended, 



112 PHYSIOLOGY AND GENERAL PATHOLOGY. 

and they appear to the waking man not merely without the will but in 
spite of it. 2. They are sometimes the false impressions of dreams con- 
tinued in the waking state. 3. They are not merely vivid reproductions 
of former impressions on the senses, but new combinations and creations. 
4. They often occur in persons in no way remarkable for talent or ima- 
gination. 5. They are often dependent on such changes in the balance 
of the cerebral circulation as occur in sleep, or in comparatively trivial 
departures from health. In Nicolai, they were clearly traced to the 
suppression of a hemorrhoidal discharge, and the immediate excitement of 
a fit of passion. 6. They are not what it would not be unreasonable to 
suppose them to be, mere reflex impressions on the retina, originating in 
the brain, and conveyed back through the optic nerve ; for they occur 
in blind persons, and in cases in which the optic nerve has been found 
so injured or diseased as to be unable to perform its proper function. 

523. The tearing of these facts on the phenomena of unsound mind 
is obvious. If a change in that part of the brain by which impressions 
on the senses are perceived, or of the whole brain, can conjure up illu- 
sions of the senses so like realities as to require a strong effort of the 
sound mind to distinguish them, it is reasonable to suppose that those 
parts of the biain which bear to thought, emotion, and passion, the same 
relation as these perceiving portions do to sensation, or the entire brain, 
as the case maybe, may undergo such changes as shall generate involun- 
tary imaginations having no foundation in fact, words without meaning, 
emotions springing from no sufficient cause, and passions admitting of 
no contiol. 

524. The same impressions on the organs of sense which, when they 
occur to waking persons, are called illusions, form, as already stated, 
the very staple of our dreams, which have an air of reality, partly due 
to the vividness of the impressions, and partly to their not beino- cor- 
rected by the judgment. But this is true, not only of impressions on 
the senses : it holds good equally of mental operations, which often do 
not suffer by comparison with similar operations voluntarily and con- 
sciously performed in our waking state. It would seem, therefore, that 
that change in the state of the brain, whatever it be. which in waking 
persons occasions illusions of the senses, gives rise during sleep to every 

; of mental delusion. 



525. These two terms, Illusion and Delusion, are here contrasted ; 
and ought not to be confounded. The distinction between them will be 
understood by the addition of three words to each : — an illusion of the 
senses, a delusion of the mind. The word phantasm may be used as a 
synonym of illusion. The term hallucination, being sometimes used in 
the sense of illusion, sometimes of delusion, ought to be allowed to fall 
into disuse. When an illusion of the senses continues to be mistaken for 
a real sensation, through inability to distinguish the one from the other, 
it becomes a delusion. 

526. Breaming is a state of mind in which illusions of the senses and 
delusions of the mind arise spontaneously while the senses are closed to 






DREAMS. 113 

the external world, and every voluntary mental effort is suspended, or 
very imperfectly exercised. 

527. Many dreams have for their exciting cause some bodily sensa- 
tion, which becomes blended with fanciful accompaniments. A blister 
applied to the head suggests a dream of being scalped by savages ; and 
a loud noise, a dream of being shot as a deserter. And, wonderful to 
relate, the sensation which really gives rise to the dream may seem the 
last link in a chain of events which would have occupied hours, days, or 
even years. The sensations caused by an oppressed stomach, loaded rec- 
tum, or distended bladder, may link themselves in like manner with 
imaginary scenes more or less appropriate. The most painful of the 
dreams due to these causes are known as nightmares. The oppression 
at the stomach is converted into a hideous personality, from whose weight 
and pressure there is no escape ; and the uneasy sensations in the rectum 
or bladder are woven into the texture of a dream, in which the impossi- 
bility of obtaining relief plays a prominent part. Excitement of the ge- 
nital organs also gives rise to a peculiar class of dreams. But these 
uneasy sensations sometimes occasion dreams which resemble the sensa- 
tion itself, only in the one particular of being painful or distressing. 
Thus a painful tumour or diseased hip-joint may give rise to distressing 
dreams having no reference whatever to the pain or to the part affected. 

528. Recent impressions on the senses, or transactions in which the 
sleeper has been engaged, also stimulate the fancy to the invention of 
connected histories of unreal occurrences. Thus, a patient of the Editor, 
suffering from obstinate colic, which had not been relieved by mechani- 
cal means, received an encouraging opinion of his case, fell asleep under 
the influence of opium, and dreamed that his doctor was an engineer to 
a railway in which he was interested, and had assured him that there 
were no engineering difficulties that might not be overcome. 

529. In many persons of unsound mind the mental operations bear an 
obvious resemblance to this class of dreams. Real sensations are mixed 
up, as in dreaming, with unreal accompaniments ; and real events pass- 
ing in the world receive fanciful interpretations, or are forced into un- 
natural relationship with their own thoughts. Thus a speculating mad- 
man who came also under the Editor's notice, when railroads, the Oregon 
dispute, and the China war, were dividing public attention, wanted to 
establish a company to run a railroad from Oregon to China. 

530. There are many striking illustrations of this analogy between 
dreaming and madness in the painfully-interesting autobiography of a 
religious maniac. The cold air which blows upon him as he tries to 
suffocate himself, in obedience to the spirits that speak within him, be- 
comes the breath of his sisters cooling him, and encouraging him to go 
through with his task. The familiar sensation of water trickling down 
the back is converted into the crystal tears of his father, whose venerable 
countenance he sees bending over him. His head is shaved, and he 
grieves that he has "received the tonsure of the Roman Catholic priest- 
hood, a mark of the beast." The jets of gas from the fireplace become 



114 PHYSIOLOGY AND GENERAL PATHOLOGY. 

the utterance of his father's spirit, attempting to save him, hut con- 
stantly ohliged to return to be purified in hell-fire, from the contamina- 
tion of his foul thoughts. The lowing of cattle conveys to him articulate 
sounds and sentences and the chair grating against the wall speaks to 
him in his father's voice. 

531 . Another convalescent from religious mania, informed the Editor, 
that he was in the habit of looking on his keeper at one moment as the 
Deity, at another as a man like himself; and that he habitually con- 
verted his footsteps into articulate words and phrases, and sometimes into 
commands to strike him. Believing obedience to be his duty, he was 
surprised and confounded to find his violence resisted. 

532. This analogy between dreaming and insanity is also well illus- 
trated by a case mentioned by Dr. Gregory, in which insanity passed, so 
to speak, into dreaming ; the maniac, for a week after his recovery, being 
harassed during sleep by the tumultuous thoughts, and violent passions, 
which had agitated him during his illness. 

533. Dreams are sometimes accompanied by voluntary acts, and per- 
sons talk or walk in their sleep, or even commit acts of fatal violence in 
their half-waking state, in pursuance of the train of thought by which 
the mind is occupied. 

534. Closely allied to this last-mentioned class of dreams is the state 
known as somnambulism, or sleep-walking, of which there are several 
varieties. In one form, the somnambulist merely goes through, with 
the precision of an automaton, a succession of acts to which he is accus- 
tomed in his waking state ; in another, he performs feats, and runs risks 
in doing them, which he would shudder at were he awake. He walks 
on the edge of a precipice, or on the top of a lofty building ; or he will 
accomplish some intellectual task which had baffled him when awake. 

535. Between this >tate of somnambulism and some forms of unsound 
mind there are analogies worth noting. In both there is sometimes a 
remarkable increase of talent, in both a complete change of character, 
and in both a distinct and separate afTection of the intellect and of the 
moral faculties — an intellectual and moral somnambulism, an intellec- 
tual and moral insanity. 

536. As evincing the change of character which sometimes happens 
during this state, the case of the Carthusian monk may be cited, who, 
while awake, was remarkable for simplicity, candour, and probity, but 
walked almost nightly in his sleep a thief, a robber, and a plunderer ot 
the dead ; or that of a pious clergyman who, in his fits, would steal and 
hide whatever he could lay his hands upon, and once even plundered his 
own church ; or the case of the suicidal somnambulist mentioned by Ray, 
who contrived to escape from his watchers, and was found suspended to 
a tree by his feet. 

537. From dreaming and somnambulism the transition is easy to 
certain states of mind, due to temporary and transient causes, readily 






DELIRIUM — DELIRIUM TREMENS. 115 

recognised, and having a close resemblance to certain forms of unsound- 
ness ; namely, delirium, delirium tremens, and drunkenness. 

538. Febrile Delirium is present in many acute diseases, in fever, and 
in inflammatory affections of the internal viscera ; it also follows upon 
severe injuries, such as burns, wounds, and fractures, and on surgical 
operations, and it is a common effect of several poisonous substances. 
There are two forms of febrile delirium. In the one the patient lies 
prostrate on his bed, utterly helpless, and muttering indistinctly. This 
form is present in the advanced stage of most cases of typhus and other 
fevers, and is known as muttering or typhous delirium. The other form 
occasionally shows itself in the early stage of fever. It is accompanied 
by great excitement, and often by great display of strength, and its re- 
semblance to mania in some cases, is so close as to lead to the patient being 
treated as a lunatic. This form is called violent or furious delirium. 

539. From the first form of delirium the patient is easily roused, by 
loud speaking, to short efforts of attention, and to the performance of 
slight muscular movements, such as protrusion of the tongue ; but he 
soon relapses into his previous state. In some cases the attendants are 
able to discover that the mind is occupied by a dream in which real per- 
sonages play a consistent part. 

540. That form of delirium known as Delirium tremens has some 
peculiarities worth noting. There are three effects of an abuse of spi- 
rituous liquors which may be usefully distinguished. The first is the 
common drinking fit, in which, when the excitement takes the shape of 
noisy anger, no mischief is done, because there is not power or steadiness 
enough in the muscles to commit the threatened violence. The second 
state has all the characters of a maniacal paroxysm, and is brought on 
in certain persons whenever they indulge to excess. It is a dangerous 
state of violent incoherence. The third form is that commonly known 
as Delirium tremens. It is sometimes the consequence of long habits of 
drinking abandoned for a time ; but in the inhabitants of large towns, 
enfeebled by sedentary occupations, overwork, or want of proper nourish- 
ment, it may be the immediate consequence of a single debauch. 

541. The characteristic symptoms of this state are trembling of the 
hands and limbs, and sleeplessness, with a pale face and moist skin. 
Sleeplessness is a constant symptom, and tremor is rarely absent. The 
patient is restless, anxious, timid, suspicious, and cunning ; and fancies 
himself in a strange place, and under a control from which he is constantly 
endeavouring to escape ; he is harassed and perplexed by spectral illu- 
sions, by strange sounds and threatening voices, and he fancies himself 
surrounded by hideous and loathsome objects, such as toads, serpents, and 
scorpions. In the midst of all these objects of horror, disgust, and annoy- 
ance, his countenance, strange to say, is often calm and composed ; he 
walks about as in a dream, and will charge a bystander with threaten- 
ing his life in a tone of the most complete indifference, as if it were im- 
material whether he fulfilled Iris threat or not. In other cases, however 



116 PHYSIOLOGY AND GENERAL PATHOLOGY. 

the patient's fears and suspicions impel him to acts of violence, and he 
becomes very dangerous either to himself or others. 

542. The important subject of unsound mind is one of such extent 
that only the merest outline of it can be given in this place. There are 
two kinds of mental unsoundness, the one consisting in imperfect develop- 
ment, generally coinciding with a defective brain, and often with a 
stunted or deformed frame, dating from birth, or manifesting itself in 
infancy ; the other supervening in later life in persons previously of 
sound intellect. 

543. The first of these forms is termed Amentia, and comprises two 
sub-classes, Idiocy and Imbecility, between which there is no clear line 
of demarcation. Both, however, imply an original defect of intellect, 
and the first a greater defect than the second. The line may be most 
conveniently drawn by placing on the one side, as Idiots, all those un- 
fortunate persons who, being otherwise of defective intellect, cannot be 
taught to speak, on the other side, as Imbeciles, those who can. The 
class of imbeciles would include those whose mental development has 
been arrested in infancy or early childhood. 

544. The idiot, thus defined, is an imperfectly-developed being, with 
a mere animal existence, obedient to the simplest calls and impulses of 
nature, incapable of being taught, dependent on others for support, and 
able, at the best, to utter a few meaningless articulate sounds. 

545. Imbeciles, on the other hand, have a certain amount of intelli- 
gence, understand what is said to them, and make themselves under- 
stood, remember common events, form habits of decency and propriety, 
and are equal to common household occupations, or to trades easily ac- 
quired. The more intelligent can be taught to read, write, and cipher, , 
and to know the use and value of money ; and they may even attain to 

a certain excellence in mechanics, music, and the fine arts ; but they 
cannot acquire the amount of knowledge, or practical skill, or exercise 
the prudence in the conduct of affairs, or the control over their passions, 
which are common among persons of their own rank and opportunities. 
The feeble control which they are able to exercise over their passions, 
coupled with the imperfect idea they acquire of moral and legal obliga- 
tions, accounts for the great number of imbeciles found among the 
criminal population. 

546. Imbeciles in the upper ranks of society, being raised above the 
temptation to crime, make their defect of character felt by every kind of 
eccentric and irregular conduct, especially by pecuniary extravagance, 
and by intemperance. Imbeciles among the middle classes furnish their 
full contingent of fraudulent debtors, swindlers, and forgers. 

547. There is, in fact, a moral as well as an intellectual imbecility, 
counterparts of the moral and intellectual insanity presently to be men- 
tioned ; and a general imbecility, combining defective intellectual deve- 
lopment with unbridled passions. Striking examples of moral imbecility, 



CRETINISM — DEMENTIA — MANIA. 117 

characterised by reckless extravagance, and an utter want of perception 
of the disgrace and wickedness of habitual debt, are to be found among 
the most eminent poets and prose writers of England. 

548. The crimes of imbeciles are characterised by the same insufficiency 
of motive, the same folly in execution, and the same futile attempts at 
concealment, which mark other parts of their conduct. 

549. Idiots and imbeciles afflicted with every variety of bodily in- 
firmity and deformity, are to be found in certain unhealthy regions in all 
parts of the world, but especially in low damp spots, shut out from in- 
tercourse with neighbours, and subject to the evil of constant inter- 
marriages. The evil reaches its highest pitch of intensity in deep alpine 
valleys, where the enlargement of the thyroid gland, known as goitre, 
is superadded to other deformities. The persons so afflicted are called 
Cretins, and their malady is termed Cretinism. 

550. The second class of unsound states of mind, or those that super- 
vene later in life in persons previously of sound intellect, comprises more 
sub-classes than the two forms just considered. Among these the one 
that most resembles idiocy and imbecility is dementia, which, as the 
name implies, consists of a loss of intellect, sudden or gradual : sudden, 
as when it arises from severe mental shocks or injury to the head; 
gradual, as when it follows attacks of fever, of inflammation of the brain, 
or of mania, and when it attends the decay of strength in the aged {senile 
dementia). Sudden attacks of dementia produce a state of mind nearly 
allied to idiocy, the attention being sometimes rigidly fixed on the train 
of thought which accompanied the shock ; while those which come on 
gradually (attended, as they often are, by epileptic seizures, and slowly- 
increasing paralysis) resemble more closely the different degrees of imbe- 
cility. Indeed, many cases which receive the name of dementia are cases 
of imbecility, not recognised as such till the capacity comes to be tested 
and strained by affairs of difficulty, or till some mental shock developes 
more completely the weak points of the character. 

551. In this class of cases it is often easy to trace the leading feature 
of the unsoundness, like a thread, through the whole history of the 
patient. An habitual debtor at school becomes an extravagant youth, 
and an embarrassed man ; as an incipient madman he thinks he has a 
divine mission involving a large outlay of money, and he dies in the full 
conviction that he is the Saviour of mankind. 

552. The remaining forms of unsound mind are comprised under the 
general term mania, which also consists of several sub-classes. Those 
commonly recognised are general mania, involving the intellect, passions, 
and emotions ; intellectual mania, involving the intellect chiefly, if not 
exclusively; and moral mania, involving the moral nature to the exclu- 
sion of the intellect. There is another term in common use, especially 
in courts of law, namely, lunacy. It is sometimes wrongly used as a 
synonym of mania, and serves to remind us of a class of cases in which 
there are intervals of sanity and freedom from excitement. The more 
correct term for such cases is mania with lucid intervals. 



118 PHYSIOLOGY AND GENERAL PATHOLOGY. 

553. Mania, whatever form it assumes, sometimes comes on suddenly 
as the result of mental shocks, intense mental excitement, severe injury 
to the brain, intoxication, or the sunstroke; but more frequently it 
makes its approaches gradually during a period often of several years' 
duration, known as the period of incubation. This period is one of pain- 
ful consciousness to the patient, and of fearful misgivings or mischievous 
misunderstandings to the friends. The bodily health suffers with the 
mind, and the disease assumes its full dimensions under the influence of 
some temporary excitement or disappointment. 

554. General mania, or that form in which the intellectual and moral 
nature are simultaneously affected, may be described as a state of raving 
incoherence, combining a vapid succession of thoughts, often brilliant and 
original, with passionate excitement and intense restlessness. Jn many 
of these cases reference is constantly being made, in language of extreme 
violence and gestures of intense anger, to events that occurred at or about 
the time of the first seizure. 

555. General intellectual mania, or that which attacks the intellect 
alone, is admitted to be of rare occurrence. There is, however, a form 
of mania in which some one emotion or passion, such as pride, vanity, 
or love of gain, obtains such ascendancy over the mind as to fill it with 
a host of intellectual delusions. Thus, patients in whom the passion of 
vanity is greatly excited, appropriate to themselves all the great intel- 
lectual performances which they have heard praised ; those in whom 
pride is predominant imagine themselves a series of great men ; and 
those in whom the love of gain is excited believe themselves engaged in 
extravagant and impossible speculations. 

556. Partial intellectual mania, or monomania, otherwise designated 
as melancholia, admits of being subdivided into two subordinate classes, 
the one comprising those cases in which the unsoundness is not connected 
with any bodily sensation, the other in which such a sensation forms an 
essential part of the malady. These latter cases are sometimes known 
as hypochondriasis, sometimes as melancholia, 

557. Cases of monomania, without uneasy bodily sensation, are of 
common occurrence, as in men who think themselves secretaries to the 
moon, or objects of persecution, or subjects of plots formed against their 
lives. In most of these cases the attack is gradual, but, like one form 
of dementia, they sometimes date from a sudden shock. Such was the 
case of Simon Brown, the dissenting clergyman, who, having killed a 
highwayman in a struggle, fancied ever after that the Almighty had 
deprived him of his immortal soul, and, stranger still, that the reigning 
monarch had the power of restoring it to him. 

558. The second class of cases of partial intellectual mania, or those 
connected with some disordered bodily sensation, are very common, and 
are remarkable not less for the extreme improbability of the interpreta- 
tion which the imagination attaches to the sensation than for its pertina- 
city. These cases are common in women, and often assume the shape 






REMAKE ABLE DELUSIONS. 119 

of imaginary pregnancy. Thus, a woman with hydatids in the womb 
thought herself pregnant by the devil ; and two females suffering from 
adhesion of the intestines after peritonitis, believed, the one, that a whole 
regiment of soldiers fought and struggled in her belly, the other, that 
the same narrow space was the scene of frequent interviews between the 
apostles and evangelists, the patriarchs and the pope. In men the ima- 
gination is not less active, nor the delusions less remarkable. Thus, one 
dyspeptic attributes his discomfort to a Caffre who got into his stomach 
at the Cape of Good Hope ; others to men on horseback ; and others 
again, forgetting their sex, believe, like the Scythians of old, that they 
have been transformed into women, and have even become pregnant. 

This form of unsoundness bears an obvious resemblance to those di earns 
which consist in an uneasy bodily sensation dressed up with imaginary 
accompaniments. 

559. Bordering on this form of unsoundness, but less easily traced to 
disordered bodily sensations, are such cases as those of the man who was 
afraid of passing urine lest he should drown the town : or of the men 
who fancy that they have noses of wax or glass, or feet of straw ; perhaps 
also the case of the woman who was afraid to bend her finger, believing 
the world to hang on it, and that of the gentleman who thought himself 
the Crystal Palace, and, when Parliament decreed its removal, accused 
it of wishing to destroy him. 

560. In the least unreasonable forms which this strange malady as- 
sumes, as when patients believe that they have frogs, toads, and serpents 
in their stomachs, cures have been effected by ingeniously-contrived sur- 
gical operations ; and their complete success would seem to imply that 
the uneasy sensations may have entirely disappeared, and yet the mental 
malady remain. 

561. One circumstance connected with this class of mental maladies, 
and w T hich applies more or less strictly to all forms of unsoundness, is 
the consistency with which the patient supports the part his fancy has 
assigned to him. If a man believes himself made of glass, he moves 
about with caution ; if of wax, he avoids the fire and sun ; if he thinks 
his head has been turned, he dresses accordingly, and, if he fancies that 
poison is being put into his food, he will eat eggs, or fruit which he has 
gathered, and drink only water which he has drawn from the spring. 

562. Closely allied to this last form, in this as in some other respects, 
is that class of cases in which, in lieu of a painful bodily sensation, there 
is an uneasy state of mind, due primarily to some painful shock or dis- 
appointment ; and passing into a belief that some person, or class of 
persons, is conspiring against the patient. Luigi Buranelli and McNaugh- 
ten were madmen of this class. Buranelli's delusion, however, was purely 
personal, while McNaughten believed himself an object of persecution to 
whole classes of the community. As these suspicions are commonly 
associated with that exaggerated estimate of the importance of certain 
bodily sensations which constitutes hypochondriasis, superficial or careless 
observers confound these cases with the more simple and harmless forms 



120 PHYSIOLOGY AXD GENERAL PATHOLOGY. 

of that disease. But experience shows that these patients are very dan- 
gerous to society. 

563. The form of mania now known as moral mania was not recog- 
nised till a comparatively recent period. Pinel has the ciedit of having 
first pointed it out, and Prichard of having forcibly directed attention 
to it. It consists in " a morbid perversion of the natural feelings, affec- 
tions, inclinations, temper, habits, and moral dispositions, without any 
notable lesion of the intellect, or knowing and reasoning faculties, and 
particularly without any maniacal hallucination." When combined with 
a like affection of the intellect it becomes general mania. It usually 
precedes the intellectual form, the delusions of the intellect springing 
out of morbid perversion of the feelings. Let this case be taken as an 
illustration. A solicitor, who, for many years, had conducted his busi- 
ness to the satisfaction of his partners and clients, had during the whole 
of that time tortured an unoffending wife by acts which no author would 
dare to commit to writing. At length he has an attack of acute mania, 
and claims to be the Deity, the Saviour, the King of England, the heir 
apparent, and other dignitaries incompatible with each other. Fiom 
this attack he recovers, has a speedy i elapse, shows signs of softening of 
the brain, and dies imbecile and paralytic. 

564. Moral mania, like intellectual mania, may be either general or 
partial. Of general moral mania Frederick William of Prussia, father 
of Frederick the Great, affords an excellent example, combining drunken- 
ness, household tyranny, religious austerity, disgusting personal habits, 
and repeated attempts at murder and suicide, with an intellect by no 
means wanting in power or culture. 

565. Partial moral mania consists in the excitement of some one 
passion or pi opensity to a degree which places it beyond the control of 
the higher faculties. In many cases the intellect and conscience remain 
intact, leading to struggles of which it is impossible to exaggerate the 
misery. The forms of this partial moral mania generally i ecognised are 
kleptomania, or a propensity to theft ; erotomania, or amorous madness 
(in females, nymphomania ; in males, satyriasis } ; pyromania, or a 
propensity to incendiarism ; dipsomania, or a propensity to drunken- 
ness ; homicidal monomania ; and suicidal monomania ; to which might 
be properly added, an irresistible propensity to lying and begging, un- 
conquerable pride, irrepressible vanity, unappeasable gluttony, and that 
most horrible form of it. lycanthropy, or wolf -mama. Of these forms 
of partial moral mania, kleptomania and pyromania are most common 
in females, the remainder in males ; but cases of all the forms may occur 
in either sex. 

566. Partial moral mania, whatever its form, is usually of some con- 
tinuance ; but there is a class of cases known as instinctive mania, in 
which the disease manifests itself suddenly, and most frequently as homi- 
cidal monomania. 

567. The history of such cases is very remarkable. The victim of 



CHARACTERS OF MANIA. 121 

the insane violence is either a perfect stranger, or an infant incapable of 
offence or a near relation, to whom the homicide is tenderly attached. 
After the fatal act no attempt is made to escape, the deed is openly con- 
fessed, and its legal punishment courted and desired. But this insane 
impulse may assume a less simple form ; the thirst for blood may be a 
chronic passion, and, like the uneasy bodily sensations and mental states 
just referred to, may clothe itself in the fantastic garb of monstrous in- 
tellectual delusions, as happened in the parricide Dadd. 

568. The forms of mania, general and partial, intellectual and moral, 
present infinite varieties, and occasion the greatest perplexity to medical 
men when they are called upon to examine patients suffering from them, 
to give evidence concerning them, or to sign certificates. This perplexity 
is increased by the very nature of the legal questions which the physi- 
cian is expected to answer — questions framed by men without experience 
of madness, and reasonably apprehensive of the injury which society 
might sustain if those who seem to be criminals should escape direct and 
speedy punishment ; but addressed to those who know what madness is ; 
who think that the truth has higher claims upon them than the safety 
of the public, or the satisfaction of those ignorant and thoughtless persons 
whose ready assent to received doctrines constitutes public opinion ; and 
who, it should be added, deem imprisonment for life in a gaol or a mad- 
house a more serious matter than death itself. 

569. Some advantage may perhaps accrue from an endeavour to bring 
the leading characteristics of mania together into one point of view. It 
should be understood, then, that this form of unsoundness consists not 
in the loss of the mind's faculties, but in their perversion ; that the senses 
are the sport of illusions of which the patient cannot detect the unreality, 
and the mind of delusions of which he cannot perceive the inconsistency 
or impossibility ; that real sensations become, as in sleep, the materials 
of imaginary scenes; that the realities by which the patient is sur- 
loundei are blended with illusions, and real persons made to undergo 
strange transformations in obedience to his delusions ; and that many of 
his strange antics and acts of violence are mixed results of his illusions 
and delusions. It ought also to be understood that the state of the 
patient's mind is subject to great variation from external and internal 
causes ; that the transition from one state to another is often as rapid as 
thought itself ; that he is capable of exercising, for considerable intervals 
of time, an extraordinary control over himself, so as to be able to conceal 
his delusions ; that, though sometimes easily imposed upon, he often 
evinces, in carrying out his insane purposes, all the forethought and pre- 
paration of a sane man ; that in his wildest excitement he is often so 
tar conscious of what he is doing as to recollect it many years afterwards, 
his statements being confirmed by sane persons having cognizance of the 
facts to which the patient refers ; and that he may even be conscious ot 
his state and of the legal relations in which it places him. 

For more full and complete information on mental physiology and 
pathology, the reader is referred to such works as Abercrombie on the 
Mntellectual Powers,' or to special treatises on Insanity. 



122 SYMPTOMS AXD SIGNS OF DISEASE. 



CHAPTEE IV. 

SYMPTOMS AND SIGNS OF DISEASE. 

The symptoms and signs of disease which are deserving of special con- 
sideration are, the urine, the pulse, the heart's beat, and the respiration. 
Others, as the tongue, the sputa, the evacuations from the bowels, the 
attitude of the body, and the expi ession of the countenance, are of less 
importance. The symptoms and signs first named will therefore be 
treated in separate sections, together with the examination of the abdo- 
minal and thoracic cavities ; the remainder will be treated of collectively 
in one section. The contents of the present chapter may therefore be 
conveniently arranged as follows: — 1. The Urine; 2. The Abdomen; 
3. The Chest, and the organs of Respiration and Circulation ; 4. The 
Pulse; 5. The Respiration ; 6. Other Symptoms and Signs of Disease. 

1. THE TJRIXE. 

Properties of Healthy Urine, 

570. Physical Properties. — Healthy urine, recently voided, has the 
temperature of the body, is perfectly transparent, and of a light amber 
colour, has a peculiar, but not unpleasant odour, which disappears on 
cooling, a salt and bitter taste, and a specific gravity ranging from 
1005 to 1033. 

571. Chemical Properties. — It has a slight acid reaction, remains 
unchanged when heated to the boiling point, and yields precipitates with 
the salts of baryta, silver, and lead, but none with the mineral acids. 
Oxalic acid produces a slight clond of oxalate of lime, and the free alkalies 
throw down a precipitate of the phosphate of lime. Tannin causes a 
slight cloudiness. 

572. Decomposition. — After standing some time, slight clouds of 
mucus form, and slowly sink to the bottom of the vessel. An unplea- 
sant odour is soon perceived, and the urine takes on an alkaline reaction, 
and effervesces with acids. Carbonate of ammonia is formed by decom- 
position of the urea, and theammoniaco-magnesian phosphate with phos- 
phate of lime are thrown down. Part of these salts entangled by mucus 
form a scum in which we may detect, by the microscope, crystals of 
ammoniaco-magnesian phosphate, amorphous phosphate of lime, and the 
constituents of mucus. Decomposition continuing to advance, the odour 
becomes more disagreeable ; a blue or grey mould forms on the surface ; 
and prismatic and leathery crystals of triple phosphate, and amorphous 
phosphate of lime, collect at the bottom, or cling to the sides of the vessel. 



CONSTITUTION AND QUANTITY OF THE URINE. 123 

573. Constituents. — These are either organic or inorganic. The 
organic constituents consist of urea, uric (lithic) acid, hippuric and 
lactic acids, salts of ammonin, and extractive matters, with small quan- 
tities of creatine and creatinine. The inorganic consist of carbonic, 
hydrochloric, sulphuric, and phosphoric acids, combined with soda, potash, 
magnesia, and lime, with traces of silica. These matters are dissolved 
or suspended in a variable quantity of water. 

574. The variation in the quantity of water, and of the solid consti- 
tuents, due to age, sex, time of day, character of food, and amount of exer- 
cise, renders it impossible to give more than an approximate analysis of 
this fluid. The following in round numbers is a rude approximation 
to the mean of seveial recorded analyses : — 



Water 


. 950 




Urea 


. . 


25 


Uric Acid 




1 


Fixed Salts 




14 


Organic Matter . 




10 




950 


50 


Total 


. 


— 1000 



Max. 


Min. 


Mean. 


500 


300 


420 


16 


14 


15 


509 


258 


381 


120 


81 


103 


68 


45 


59 


19 


14 


16 



575. The solid residue, after removing the variable element of water, 
will be seen from the following table, which is also founded on several 
analyses, to be subject to much variation : — 

Urea ..... 

Uric Acid . 

Extractive Matter, Chloride of So- 
dium and Salts of Ammonia 
Alkaline Sulphates 
Alkaline Phosphates . 
Phosphate of Lime and Magnesia . 

576. Quantity. — The quantity voided in twenty-four hours varies 
in different persons, and in the same person at different times. The fol- 
lowing are estimates of authors : — Haller, 49 oz. ; Simon, 45 oz. ; Keill, 
38 oz. ; Christison, 35 oz. ; Prout, 32 oz. (30 oz. summer and 40 oz. 
winter) ; Raver, 21 to 57 oz. ; Dalton's experiments on his own person, 
48 J oz. ( November), 51 J oz. (June). Average about 41 oz. It may, 
therefore, be stated at about tw^o imperial pints. 

577. The quantity of urine in health is chiefly determined by the 
liquid taken into the stomach ; but it is affected by many other causes. 
It varies inversely as the pulmonary and cutaneous exhalation ; and is 
greater in winter than in summer, on cold than on warm days, in moist 
than in dry air ; during the day than during the same number of hours 
at night, and in the morning than in the evening. It is also increased 
by excitement and anxiety of mind. 



124 SYMPTOMS AND SIGNS OF DISEASE. 

578. In disease, also, the urine is increased whenever the pulmonary 
and cutaneous transpiration is suppressed, excepting only those cases in 
which all the secretions are simultaneously diminished by higli febrile 
action. In the cold stage of ague, under strong nervous excitement, and 
in hysterical paroxysms, an increased flow takes place. This increase, 
which may amount to 30 or 40 pints daily, is not accompanied by any 
change in the solid constituents. But in other cases the increase of water 
is attended by increase of solid contents, or by the introduction of an 
abnormal constituent, such as sugar or chyle. 

579. On the other hand, the urine is diminished by increase of the 
cutaneous and pulmonary transpiration, by profuse diarrhoea, and in 
cholera ; by haemorrhage ; in dropsy ; in many forms of acute inflamma- 
tion ; and in the inflammatory stage of fever. It is suppressed, or greatly 
diminished, in inflammation of the kidney, and under the operation of 
active irritant poisons. 

580. The quantity of the solid constituents is also subject to con- 
siderable differences in healthy persons. The most important constitu- 
ents, urea and uric acid, are at a maximum in men in the prime of life, 
less abundant in females, and at a minimum in old age and childhood. They 
are increased by exercise and diminished by rest, increased under an 
animal diet, and diminished when vegetable food only is taken. 

581. Density. — This ranges from 1005 to 1033, and averages 1020 
or 1025. Simon assigns it a range of 1005 to 1030, and an average of 
1012 ; and Dr. J. C.^Gregory a range for the adult of 1005 to 1033, 
the greatest range in the same individual being 21, and the ordinary 
range 15 degrees. The average deduced from 363 experiments on 50 
individuals was 1022*5, and from 5 individuals, whose urine was ex- 
amined between 20 and 50 times each, 1025' 2. 

582. The urine is more dense in males than females ; and the density 
increases from childhood to manhood, to fall again in old age ; it is in- 
creased by hot weather, much exercise, free perspiration, a dry diet, nitro- 
genous food, and during sleep. It is diminished by cold, sedentary habits, 
a watery diet, vegetable food, and acids ; also by alcoholic fluids. It is 
at its average in the morning on waking ; falls considerably after break- 
fast ; rises gradually after mid-day ; sinks immediately after dinner, but 
in a few hours rises higher than at any other time : and in the course ot 
the night gradually returns to its average. 

583. The urine secreted after the digestion of food differs widely from 
that formed after fluids have been taken. The former, the " urina chyli," 
contains, according to jSysten, thirteen times as much urea, sixteen times 
as much uric acid, and four times as much saline matter as the latter, 
the " urina potus." It has also an alkaline reaction. 

584. The density of the urine in disease may vary from 1001 to 1055; 
and as the density in health does not appear to fall below 1005, nor rise 
above 1033, it follows that any number below 1005 and above 1033 
should be regarded as a sign of disease, and any number approaching 
either limit should attract attention. A less density than 1 005 indicates 



THE UKIXE IX DISEASE. 125 

an increase of water, with a decrease of some of the solid constituents. 
A greater density than 1033 affords a strong presumption of diabetes, 
though 1030 — 1035 has been observed in cases of increased secretion with 
excess of urea. 

585. The solids discharged in the urine in 24 hours average less than 
an ounce and a half. In a vigorous healthy adult male they may be 
taken at two ounces, or nearly 1000 grains. In disease they have been 
known to rise as high as 36 ounces, and to fall as low as 11 grains. 

58 6. The colour of healthy urine is inversely as its quantity; when 
scanty, it is high-coloured ; when abundant, pale. In the morning it is 
usually of a darker tint than later in the day. In disease, also, the colour 
bears some proportion to the quantity ; but it is materially affected by 
diseased products. It may be white, or bluish-white, and turbid from 
the admixture of chyle, milk, mucus, or pus, or of the earthy phosphates 
in excess ; deep yellow, or greenish yellow, from bile or cystic oxide ; da v k 
red or purplish, from the purpurates, as in inflammatory diseases ; yei- 
low-red, as in hectic and the sweating stage of ague ; brownish or cherry- 
red, from the admixture of the red particles of the blood; black, from 
melanic, and blue, from cyanuric, acid. Several substances taken with 
the food, such as rhubarb, madder, beet-root, corn-poppy, and log-wood, 
are also said to tinge the urine red. 

587. The natural odour of the urine, best perceived when it is scanty 
and high-coloured, disappears with dilution. It is altered by some kinds 
of food, such as asparagus ; is aromatic in many nervous affections ; am- 
moniacal in injuries of the spinal cord ; putrid from admixture of pus or 
mucus, in diseases of the urinary organs, and in putrid fevers ; sweetish 
in diabetes mellitus ; and it has the odour of sweetbriar or of violets 
when it contains cystine, and probably under other circumstances. 

588. The taste of the urine is perceptibly sweet in well-marked cases 
of diabetes mellitus. 

The Urine in Disease. 

589. The abnormal conditions of the urine are of two kinds : — 

(1.) Its normal constituents may be in excess or defect. 

(2.) It may contain substances foreign to its normal composition. 

This second class admits of further subdivision as follows : — 

(1.) Salts of ammonia and lime, of which the constituents exist in 
healthy urine, namely, carbonate and oxalate of lime, and carbonate of 
ammonia. 

(2.) Substances which result from the imperfect assimilation of the 
food, or from defective elimination in the kidney; namely, chyle, fat, 
milk, sugar, bile, and cystine, to which may be added kyestein, found 
chiefly in the urine of pregnant women. 

(3.) Blood; or its constituent red particles, fibrine, and albumen. 

(4.) Secretions of the membrane lining the urinary organs ; namely, 
mucus, and epithelial scales (these exist in small quantity in healthy 
urine), pus, and casts of the urinary tubes. 



126 SYMPTOMS AXD SIGNS OF DISEASE. 

(5.) Animal secretions derived from neighbouring organs, as semen 
and the gonorrheal and leucorrhoeal discharges ; also entozoa, 
(6.) Poisons and medicines. 

Examination of the Urine. 

590. For this purpose we resort to chemical tests and the microscope. 
Our tests have to be applied either to the urine as it is passed, or after 
it has remained at rest for some time, and we may have to examine both 
the clear supernatant portion and the deposit. The microscope is used to 
identify the deposited matters, or those thrown down by chemical reagents. 

591. Tests. — Those in most common use are turmeric and litmus 
paper, heat and nitric acid. Hydrochloric and acetic acids, liquor am- 
monias, and liquor potassae, are also frequently employed ; and, for certain 
purposes, alcohol, and solutions of oxalate of ammonia, of sulphate of 
copper, and of oxalic acid, are needed. A spirit-lamp, and fragment of 
platinum foil, and an uiinometer, or 1000 grain bottle, complete the list 
of apparatus commonly required. 

592. For microscopic examination we require a few conical glasses 
(wine-glasses will answer the purpose) and a pipette. The deposits are 
allowed to collect for several hours in the bottom of the glass, are then 
drawn off by the pipette, and transferred to a glass cell ; or a di op of the 
urine is placed on a glass slide, and protected by a fragment of thin glass. 

593. The urine submitted to examination should be either an average 
specimen of the entire day, or the first voided in the morning. It should 
be protected by a cover, and care should be taken to avoid the intro- 
duction of extraneous matters. Those likely to be tound in the urine 
are depicted in Dr. Beale's " Use of the Microscope in Clinical Medicine 
Illustrated." 

594. In order to present a complete view of this subject, the princi- 
pal indications of the tests will first be described, and then the chemical 
and microscopical properties of the several constituents of the urine. 

Turmeric paper is changed from yellow to brown by alkaline urine ; 
blue litmus paper to red when the urine is acid. Heat thiows down 
albumen, and also the phosphates when in excess, but it dissolves the 
urates of soda and ammonia. Nitric acid. — This throws down a dead- 
white precipitate of albumen ; it precipitates uric acid after some hours, 
and dissolves it with effervescence ; it also dissolves the oxalate of lime 
and the alkaline and earthy phosphates; it precipitates the colouring 
matter of bile of a green colour, but if added in excess, it changes it 
quickly, first to a dingy red, and then to a brown ; it also detects urea 
in excess, when added to an equal quantity of urine, by the formation of 
crystals of the nitrate. Moreover, it produces a cloudiness in urine con- 
taining certain essential oils. Hydrochloric acid precipitates uric and 
hippuric acid, and throws down the colouring matter of the bile of a 
green colour, whatever the quantity added. It also dissolves the oxalate 
of lime, cystine, and the phosphates. Acetic acid produces a cloudiness 



TESTS FOE URINE — UREA. 



127 



in urine containing mucus ; it dissolves the alkaline phosphates, and the 
phosphate of lime sparingly. Sulphuric acid added to warm urine 
containing sugar or albumen, causes a deposit of carbon. Caustic am- 
monia throws down the earthy phosphates as a white precipitate, and 
dissolves cystine ; its vapour imparts a rich purple hue to the crystals of 
uric acid. Oxalic acid in solution throws down a characteristic oxalate 
of urea. Oxalate of ammonia is used to detect the presence of the phos- 
phate of lime. Caustic potash dissolves uric acid and the urates of soda 
and ammonia, and with the aid of heat disengages ammonia from the 
urate ; it also tinges saccharine urine a dark-brown, and thickens puru- 
lent deposits. A solution of sulphate of copper, rendered strongly alka- 
line by caustic potash, when heated with saccharine urine, detects the 
sugar by causing a deposit of the red oxide of copper. Alcohol, by the 
aid of heat, dissolves cholesterine and hippuric acid. 

The following are the chemical and microscopic characters of the prin- 
cipal constituents of the urine in health and disease. 

595. Urea. — This in excess gives a high specific gravity to the urine 
(1*030 — 1*035). If abundant, it may be detected by adding to a 
little urine in a watch-glass an equal bulk of 
strong nitric acid. The mixture, if kept in a 
cool place, deposits crystals of nitrate of urea. 
When the quantity of urea is small, we evapo- 
rate before applying the acid. 

The best process for detecting urea and ob- 
taining well-formed crystals of the nitrate is 
the following : Evaporate some urine over a 
water-bath to the consistence of a syrup ; add 
strong alcohol, filter the alcoholic solution, and 
evaporate it nearly to dryness : add a few drops 
of water and of strong nitric acid. Crystals 
of nitrate of urea are speedily formed, which 
assume, under the microscope, the form de- 
picted in Fig. 12. For practical purposes the presence of urea may be 
readily detected by evaporating a few drops of urine on a glass slide, 
and adding an equal quantity of nitric acid. 



Fig. 12. 




Fig. 13. 



Fig. 14. 





It we substitute oxalic for nitric acid, we obtain crystals of the form 
shown in Fig. 13. The alcoholic extract of urea leaves, on spontaneous 
evaporation, acicular crystals of the form shown in Fig. 14. 



128 SYMPTOMS AND SIGNS OF DISEASE. 

596. Uric Acid. — Uric or lithic acid sometimes exists in the urine in 
such quantity as, on cooling, to separate from it in the ibrm of a crystal- 
line deposit. It is occasionally voided as gravel, and is a frequent con- 
stituent of urinary calculi. In urinary deposits it has every tint from 
light yellow to deep orange-red, or dark-brown. Hence the familiar 
names of "yellow and red sand." Occasionally it is quite free from 
colour. 

Urine which yields uric acid deposits has generally a high colour, an 
acid reaction, and a specific gravity of 1*020 or more. The acid may 
be separated from urine which yields no deposit on cooling, by adding 
hydrochloric acid in the proportion of two or three drachms to six or 
eight ounces. The mixture, after standing in a covered vessel for 
twenty-four to forty-eight hours, yields a red or reddish-brown sediment 
of uric acid. 

The crystals also vaiy in size from grains visible to the naked eye, 
and known as Cayenne pepper grains, to a fine sand, in which the 
characteristic forms of the crystal are only to be detected under high 
powers of the microscope. 

597. Uric acid is insoluble in hot and cold water: is not redissolved 
when the urine is heated ; is very soluble in caustic potash, and is pre- 
c ; pitated granular and colourless from this menstruum by the addition 
of an acid in excess : it is dissolved by nitric acid with effervescence, and 
on evaporation to dryness yields a red or pink residue, which is changed 
to a rich purple (inurexide y by vapour of ammonia. Heated on platinum- 
foil uric acid burns, gives out an odour of bitter almonds, and leaves a 
scanty white ash ; when heated on porcelain it yields a crystalline sub- 
limate to a superimposed disk of glass. 

Under the microscope uric acid displays a great variety of forms. Its 

Fig. 15 




proper shape is rhomboidal ; but it may assume one or other of the forms 
shown in fig. 15, some of which are comparatively rare. (One member 
of the group represents the acid crystallized on a hair.) 

598. Hippuric Acid. — This, which abounds in the urine of herbivo- 
rous animals, exists also in human urine. It may be obtained by evapo- 
rating a few ounces of urine to the consistence of syrup, and adding 
hydrochloric acid in excess. A mixture of uric and hippuric acids is 
thrown down. This deposit, having been washed in cold water, is 
boiled w T ith alcohol, which dissolves the hippuric acid. On evaporating 



URATES — OXALATE OF LIME. 



129 



Fig. 16. 



the spirituous solution, the acid is deposited in the form represented 
in Fig. 16. 

599. The Urates or Lithates. — These de- 
posits are often very abundant, generally fall- 
ing as the urine cools, but occasionally they 
are voided with it. They are rarely quite 
white, sometimes bright red, and they may 
assume any tint from light yellow to dark 
brown. They are soluble in warm water 
and in warm urine. Alkalies dissolve them, 
and acids in excess throw down crystals of 
uric acid, which, when treated successively 
with nitric acid and ammonia, yield the rich 
purple murexide. 

600. Urate of Ammonia. — This salt is sometimes diffused through 
the urine, so as to give it the ropy appearance of muco-pus ; in other 
cases it forms a whitish or a reddish-b>ovvn deposit, known as the lateri- 
tious or brick-dust sediment. 

Urate of ammonia shares with the other urates the properties enume- 
rated in § 599 ; but it has the characteristic property of giving out 
ammonia, when heated with liquor potassse. Its microscopic appearance 
is depicted in Fig. 17. The granular deposit known as urate of ammonia 
often consists of the mixed urates of soda, ammonia, lime, and magnesia. 




Fig. 17. 



Fig. 18. 








601. Urate of Soda. — Is rare as an unmixed deposit, but is some- 
times met with in gout, and in fever patients treated with carbonate of 
soda. It has the chemical properties common to the urates. It tinges 
the outer flame of the blowpipe yellow. Under the microscope it presents 
the characteristic form seen at a, Fig. 1 8 ; b being a rare variety (Beale). 

602. Oxalate of Lime. — This is rarely seen as a granular deposit, but 
is often diffused through the urine as minute octahedral crystals. It is 
a common constituent of urinary calculi, and the material of the " mul- 
berry calculus." It is insoluble in water, liquor potassse, and acetic acid ; 
but soluble in nitric acid, and converted at a red heat into carbonate of 
lime, identified as such by dissolving with effervescence in acids. 

603. Oxalate of lime may be obtained for chemical or microscopic 
examination by allowing one or two ounces of the urine to stand for a 
few hours in a conical wine-glass. Part of the lower stratum is then 
withdrawn by the pipette, placed in a watch-glass, and gently heated . 



130 



SYMPTOMS AND SIGNS OF DISEASE. 



Crystals of the oxalate are deposited, and may be collected at the bottom 
of the glass by carefully rotating the fluid. After allowing it to be at 
rest for a few minutes, the fluid portion may be withdrawn by the pipette, 
its place being supplied by distilled w T ater. The white glistening pow- 
der, again collected in the centre of the glass by gently rotating it, may 
be transferred by the pipette to the field of the microscope. 

604. The crystals of oxalate of lime so obtained generally appear 
under the microscope as flattened octahedra, with one short axis and two 
longer ones (Fig. 19) ; but they may also assume the form known as the 



Fig. 19. 



Fig. 20. 





<g> 






co ^ o 



dumb-bell crystal (Fig. 20). Crystals of this shape are believed to be 
generally, if not always, formed in the kidney itself. They diifer from 
the octahedra inasmuch as they polarise light, and are perceptibly acted 
on by acetic acid, which destroys their polarising power. Dumb-bells 
more or less perfect are depicted in Fig. 20. Both octahedra and dumb- 
bells are found adhering to casts of the urinary tubes. Octahedra so 
adhering are shown in Fig. 35, p. 138. 

605. The Phosphates. — Phosphoric acid exists in urine in combina- 
tion with alkaline and earthy bases, as, 1. The ammonio -phosphate of 
magnesia, or the triple phosphate. 2. The ammonio-phosphate of mag- 
nesia, with excess of ammonia, known as the basic or bibasic phosphate. 
And 3. Phosphate of lime. These deposits have the following properties 
in common. They generally occur in neutral or slightly-alkaline urine ; 
are white unless tinged with blood ; are not dissolved by heating the urine 
which contains them, but are, on the contrary, thrown down by heat ; 
they are soluble in weak acids, but insoluble in water, in ammonia, and 
in liquor potassae. The phosphate of lime is less soluble in acids. Heated 
separately they fuse with great difficulty ; but when combined in nearly 
equal proportions, the phosphate of lime and the triple phosphate fuse 
readily, constituting the fusible calculus. 

606. 1. The ammonio-mcgnesian phosphate , or triple phospMte. — 
On adding a few drops of ammonia to healthy urine, it becomes turbid, 
and deposits the triple salt combined with phosphate of lime. The 
same result may happen from the development of ammonia or its car- 
bonate when the urine is retained in the bladder for a long time, as 
in cases of paraplegia, or allowed to stand some hours out of the body. 
It is also common in diseased states of the mucous membrane of the 



CHYLOUS UKIXE. 



131 




A 



:\, 



A 



w 



V 



bladder. The triple phosphate may present itself in any of the follow- 
ing forms : — a. As a white crystal- 
line gravel, b. As a thin iride- 
scent film on the surface of the 
urine, c. As a dense white deposit 
closely resembling mucus, d. In 
masses or ropes resembling muco- 
pus. Under the microscope the 
triple phosphate assumes some of 
the annexed forms. It is very com- 
mon as triangular or four-sided prisms with truncated ends (Fig. 21). 

Fis; 22 

607. 2. The basic or bibasic 'phosphate 

(triple phosphate, with excess of ammonia) 
has the microscopic characters shown in 
Fig. 22. 

3. The phosphate of lime occurs as an 
amorphous deposit, or in little rounded 
particles, usually found adhering to the crystals of the triple phosphate. 

608. Cystine. — This curious substance is characterised by the great ex- 
cess of sulphur that enters into its composition. It is not found in healthy 
urine, and is a rare product of disease. It constitutes a form of urinary 
calculus, but very seldom exists as a deposit, 
it is usually of a pale-yellow tint, of 
low specific gravity, and of an odour 
resembling sweetbriar. The deposit of 
cystine is white, or of a pale-fawn 
colour, distinguished from white urate 
of ammonia by not disappearing on 
heating the urine which contains it; 
and from the earthy phosphates by its 
insolubility in dilute hydrochloric or 
strong acetic acid. It is at once dis- 
tinguished from all other deposits by its ready solubility in ammonia. 
The crystals are hexagonal plates of variable thickness, but generally 
thin, and often superimposed, as hi Fig. 23. The 
ammoniacal solution yields, on evaporation, the same 
well-formed hexagonal plates or prisms, but some- 
times the clustered crystals figured in the engrav- 
ing. Cystine is often found blended with uric acid 
and the urates. 

609. Chloride of Sodium. — Common salt some- 
times appears as crystals on evaporating the urine. (J / 
Their proper form is the cube, but on hasty evapora- \j 
tion they have an irregular cruciform appearance <^\ 
(Fig. 24). Sometimes, as in the figure, they are ^^ :\j 
octahedra. 

610. Chyle, — Chylous urine, on cooling, gelatinises spontaneously, as- 



The urine which contains 
Fig. 23 




Fig. 24. 






s *j 



<r 



132 SYMPTOMS AND SIGNS OF DISEASE. 

suming the appearance and consistence of blanc-mange. It contains large 
quantities of albumen and fat. 

611. Fat. — Urine may contain fat in a separate form, or as a consti- 
tuent of chyle or milk. It is also frequently met with in the shape of 
oil-globules attached to epithelial cells, or casts of tubes. (See § 383, 
Fig. 7 b, and § 628, Fig. 33.) The quantity of fat maybe ascertained 
by evaporating a portion of the urine, dissolving the deposit in ether, 
evaporating the solution, and weighing the residue. 

612. Milk. — Urine containing milk is turbid and pale, and contains 
fat globules and colostrum corpuscles. Milky urine does not coagulate 
by heat, unless the quantity of lactic acid be large, or unless it also con- 
tains albumen. On adding to a little urine moderately warmed a few 
drops of acetic, dilute sulphuric, or hydrochloric acid, flocculi of coagu- 
lated caseine are formed. The quantity of caseine may be determined 
by collecting these flocculi, washing and drying them, and dissolving out 
the oil-globules by aether. 

613. Sugar. — This may sometimes be detected by the taste, especially 
if we first evaporate the urine to the consistence of a syrup ; but this 
test is inconvenient in practice, and not to be depended on. The specific 
gravity of the urine affords certain evidence of the existence of sugar only 
when it exceeds 1*035, which is probably the highest figure for urine con- 
taining urea in excess. The specific gravity of diabetic urine ranges from 
1*020 to 1*050. When the symptoms lead to a suspicion of the presence 
of sugar, it may be detected by one or more of the following tests : — 

(1.) Trommers Test. — Add solution of sulphate of copper till the 
urine has a faint blue tint ; then add liquor potassse in excess. Hydrated 
oxide of copper is thrown down, but dissolves in the excess of alkali. On 
boiling the liquid, if sugar be present, the red suboxide of copper, vary- 
ing from a light orange to a deep crimson tint, is thrown down. 

(2.) Fehling's Test-solution. — This may be conveniently substituted 
for the sulphate of copper and caustic potass of Trommer's test. It is 
prepared by dissolving 69 grains of sulphate of copper in five times its 
weight of distilled water, and adding a concentrated solution of 268 
grains of tartrate of potash, and then a solution of 80 grains of caustic 
soda in one ounce of distilled water. 

The following tests have been recommended, but are less free from 
objection than the foregoing : — 

(3.) Moore's Test, with liquor potasses. — Pour the urine supposed to 
contain sugar into a test-tube, add half its bulk of liquor potassse, and 
boil for one or two minutes. The urine assumes an orange-brown tint 
of depth proportioned to the quantity of sugar. 

(4.) Lunge's Test, with dilute sulphuric acid. — Evaporate a small 

quantity of the urine on a surface of white porcelain, add to the warm 

few drops of dilute sulphuric acid (one acid to six water). If 

sugar be present, a deep brown or black deposit of carbon is formed. This 

test is delicate, but not conclusive, as albumen yields a similar result. 

(5.) Capezzuolis Test. — Drop into the urine a few grains of the blue 
h yd rated oxide of copper, and then add a little liquor potassse, so as to 



TESTS FOR SUGAR AND BILE. 133 

render the liquid alkaline. If sugar be present the fluid assumes a reddish 
tint, and in a few hours the fragments of the oxide turn yellow, first at 
the edges, and then through the whole mass : this arises from the redac- 
tion of the oxide to the suboxide. 

(6.) Horsle;fs Test. — Add to the urine an alkaline solution consist- 
ing of chromate of potass and liquor potassas, in equal proportions, and 
boil. The liquid will assume a deep sap-green colour, due to the reduc- 
tion of the oxide of chromium. 

(7.) Crystallization Test. — Evaporate the urine to the consistence of 
a thick syrup, and digest in hot alcoiiol. Pour the cooled alcoholic solu- 
tion into a large test-tube, and allow it to evaporate spontaneously. The 
sugar will crystallize on the sides in white granules. 

(8.) Fermentation Test. —On adding yeast to diabetic urine, and 
raising the temperature to 80°, effervescence takes place, a brisk dis- 
charge of gas ensues, and a yellowish liquid is formed, 
which has the odour of beer, and yields alcohol by 
distillation. One part of sugar in 1000 parts of 
healthy urine of tne density 1030 may be detected 
by this means. The test was first suggested for ani- 
mal fluids by Gmelin, and for urine by Christison. 

( 9.) Torula Test. — Expose the urine for a few hours 
to a temperature above 70°. A drop taken from the 
scum that covers the surface, and placed under the 
microscope, exhibits oval vesicles, which rapidly grow 
into a species of conferva, to which the term toruli 
has been given. This formation, however, is not 
peculiar to diabetic urine. (Pig. 25.) 

614. The quantity of sugar may be determined with a fair approach to 
accuracy by the Fermentation test, which is thus performed. A gra- 
duated tube is filled with mercury, leaving space for little more than the 
requisite quantity of urine, which is then introduced. What remains 
of the space is filled with yeast. The open end of the tube is then closed 
with the finger and reverse:! in a vessel of mercury. The graduated 
tube is then exposed to a heat of 70° or 80° for twelve hours or more. 
Since the fluid thus introduced dissolves its own bulk of carbonic acid, 
the measure of the fermented liquid added to that of the undissolve! 
gas, will give the quantity of carbonic acid; from which the weight of 
sugar is inferred by allowing one grain for every cubic inch of gas. 

615. Bile. — Urine containing bile is of a deep yellow-brown colour, 
and if the quantity be considerable, of a bitter taste. The bile may be 
detected by any of the following tests : — 

(1.) Nitric Acid. — To a few drops of the urine on a white surface of 
porcelain, add a drop of nitric acid. If bile be present, green and pink 
colours will show themselves. 

(2.) Pettinkoffers Test, Sulphuric Acid and Sugar. — To a few drops 
of the urine on a white surface of porcelain add a drop or two of strong 
sulphuric acid, and, while the mixture is hot, add a drop of strong syrup. 
If bile be present a fine purple colour will be produced. 




134 SYMPTOMS A^D SIGNS OF DISEASE. 

(3.) A third test has been proposed by Schwertfeger. It consists in 
throwing down the bile as a yellow precipitate, by acetate of lead, and 
dissolving the precipitate in alcohol acidulated with sulphuric acid. To 
the green solution thus obtained, Pettinkotfer's test may be applied. 

Tests 1 and 2 are most expeditious, and, therefore, to be preferred. 

616. Kyestein. — This, though not peculiar to pregnant women, is 
found in most cases of pregnancy. It cons : sts of a film of fat, a matter 
resembling caseine, and crystals of ammoniaco-magnesian phosphate. It 
forms upon the surface of the urine in periods varying from thirty hours 
to eight days, but generally on the third day. The urine is either neutral 
or ammoniacal at the time of its formation. After standing some time 
the pellicle breaks up and falls to the bottom. The sediment has the 
disagreeable pungent odour of decayed cheese. 

617. Blood. — Blood is sometimes voided with the urine in small de- 
fined clots, readily recognised ; but, in other cases, it tinges the urine a 
bright red, brown, or bistre-red. The colour alone is not conclusive, as 
other colouring matters produce similar appearances ; but its nature is 
easily ascertained, either by the discovery of blood corpuscles under the 

microscope, or by the effect of heat and nitric 

Fis. 26. acid, which throw down a dirty-brown coagu- 

n^ O lum, consisting of albumen blended with the 

E* G ® © ^ colouring matter. The urine also assumes a 

O <?J§& ^> 0% bright-red tint when treated with a strong 

® G> °' ^ solution of common salt. 

© ^ 

618. Blood Corpuscles. — When not dis- 
solved in the urine, the blood corpuscles form a dark brown -red sediment, 
in which their forms (see Fig. 26) may be detected by the microscope. 

619. Fibrine. — This substance is voided in the form of casts of the 
tubes, or as a constituent of clots of blood. Coagula and flocculi of fi- 
brine are readily distinguished from mucus by their amorphous appear- 
ance under the microscope, and the absence of epithelial scales. 

620. Albumen. — Tests — heat, and nitric acid. These should always 
be employed at the same time. For heat will throw down the phosphates 
if they be in excess, and the acid may render the urine turbid if it con- 
tains an essential oil, as that of cubebs or copiaba. Should the phos- 
phates in excess coexist with an essential oil, both heat and nitric acid 
would throw down a white precipitate. The addition of an acid will 
dissolve the phosphates ; the essential oil may be separated by a?ther, 
after which the urine will have its usual reaction. Corrosive sublimate 
in solution is also a delicate test for albumen, but the two tests just 
mentioned are those commonly employed. 

621. Mucus. — A small quantity of mucus is present in healthy urine 
without affecting its transparency. In disease it may be blended with 
it in any proportion, from a slight cloud to a quantity sufficient to cause 
it to pour from one vessel to another as a viscid ropy fluid : and when 
the quantity is considerable, and the result of acute inflammation of the 



URINARY DEPOSITS. 135 

mucous membrane, and especially when it is blended with an excess of 
phosphates, it may form a distinct deposit closely resembling pus. Urine 
containing mucus has generally an alkaline reaction, and is not coagu- 
lated by heat or nitric acid, unless albumen be also present. Acetic 
acid coagulates it. 

622. Pus. — Urine containing pus is commonly either acid or neutral : 
and, on standing, deposits the pus as a distinct cream-coloured layer, 
readily diffused through the fluid by agitation. The deposit is not dis- 
solved by acetic acid ; it is rendered viscid and more consistent by liquor 
potassae, and, when shaken with sether, yields a quantity of fat. The 
urine, freed from its purulent deposit, is coagulated by heat and nitric- 
acid. In alkaline urine, pus has something of the viscidity of mucus. 

Under the microscope pus presents a num- 
ber of opaque spherical bodies, consisting of a Fig. 27 « 
cell-membrane enclosing nuclei, oil-globules, (gh & /tn z 
and minute granules. The addition of acetic j^N ''""" ^ (J) \z) 
acid renders the envelope transparent and the ^ (f^ ® /g\ (J) 
nuclei more distinct, as in Fig. 27, in which (§| A» ^y?\ 
a represents the ordinary appearance of the ^^ ^ 
pus granule, and 6 of the same granule on 

the addition of acetic acid. Mucus presents similar microscopic appear- 
ances, but the particles are not so distinctly granular. 

623. Diagnosis of Pus and Mucus. — Much stress was formerly laid 
on the importance of distinguishing pus from mucus, and many methods 
were devised for effecting that object. But it is now well understood 
that, though there is a great difference between pus and healthy mucus, 
there is very little between pus and the mucus of an inflamed membrane. 
The only satisfactory means of distinction is heat or nitric acid. Urine 
containing pus is coagulated by these reagents, while urine containing 
mucus is not, unless it also contains albumen derived from some other 
source. 

624. Semen. — Occasionally the semi- Fi £* 28# 

nal fluid which lines the urethra after \ _/ o \ 1 \ _, 



emission becomes washed away by the 



V, 



urine, and may be recognised in it by rf~~^ _-P \^ 

the peculiar appearance of the sper- ^ t - B "-^- 

matozoa (Fig. 28). The examination 

should be made soon after the urine is passed, with a quarter or an 
eighth power, and the object not too strongly illuminated. 

625. Epithelium. — The epithelium 
scales, which are found blended with pus 
and mucus, and are often discharged in 
large quantities, especially by persons 
suffering from the secretion of oxalate of 
lime, are easily recognised by their well- 
known microscopic characters (Fig. 29). 

626. Sometimes it is desirable to be able to form an opinion on the 




136 SYMPTOMS AND SIGNS OF DISEASE. 

spot, by inspection and the use of one or two simple tests, as to the 
character and composition of an urinary deposit. The most common 
deposits may be classed as follows :— 

(1.) Red crystalline sediment — Urine acid. Uric acid with colouring 
matter of the urine. 

(2.) White crystalline sediment — Urine neutral or alkaline. Triple 
or ammoniaco-magnesian phosphate. 

(3.) White amorphous sediment — Triple phosphate, and phosphate 
of lime. 

(4.) Pink sediments — Urine acid. Urate and phosphate of ammonia. 

(5.) Yellowish or nut-brown sediment — Urate of ammonia and soda, 
earthy phosphates, and colouring matter of urine. 

(6.) reddish-brown or lateritious sediment — Alkaline urate (chiefly 
urate of soda), earthy phosphates (occasionally), colouring matter of 
urine, and alkaline purpurate. 

(7.) Oxalate of lime. Rare as a deposit. 

(8.) Carbonate of lime "1 v 

(9.) Cystic oxide j ery rare ' 

(10.) Red particles of blood, pus, mucus, kc. 

627. The substances contained in 2, 3, 4, 5, and 6, consist of colouring 
matter with alkaline urates and earthy phosphates in variable propor- 
tions. These are easily distinguished, both from each other and from certain 
secretions which resemble them, by shaking up the sediment and apply- 
ing heat. If the sediment dissolve, it consists of alkaline urates, and 
chiefly of urate of ammonia ; but if the fluid remain turbid, the deposit 
consists of the earthy phosphates, or of pus or mucus. They may be 
readily distinguished by the addition of hydrochloric acid, which dissolves 
the phosphates, but not the pus or mucus. If urine containing urates 
also holds albumen in solution, the urine when heated first becomes clear, 
and then turbid. 

628. Casts of the Urinary Tubes. — In diseases of the kidney con- 
siderable importance attaches to a microscopic examination of the urine, 
with a view especially to the discovery of casts of the urinary tubes. 

Diseases of the kidney which have not a local origin (such as blows on 
the loins, the irritation of a calculus, or retention of urine from stricture) 
result from an effort of the kidney to separate from the blood some mor- 
bid material, such as the poison of scarlatina, measles, erysipelas, or 
typhus ; of gout, rheumatism, or scrofula. Imperfect nutrition conse- 
quent on an insufficient supply of food, or au imperfect action of the skin 
or liver, may also excite disease in the kidney ; and lastly, a disease of 
the kidney may be produced by irritant substances, such as oil of turpen- 
tine or cantharides. In all these cases the morbid products are thrown 
into the urinary tubes, and being dislodged by the urine flowing through 
them, appeal' as cylindrical casts. As each form of kidney disease is 
attended by its characteristic cast, a careful examination of these bodies 
is essential to the formation of an exact diagnosis. The casts, of which 
the chief varieties are represented in the figures, are best seen with a 
power magnifying about 200 diameters. 



CASTS OF UKINAKY TUBES. 



137 



Fig. 30. Epithelial cast, composed of fibrine, entangling epithelium 
and blood corpuscles, and indicating "acute desquamative nephritis," a 
form of disease not uncommon as a consequence of scarlatina, and which 
is analogous to the desquamation of the skin. 

Fig. 31. Granular cast, composed of fibrine, with particles of dis- 
integrated epithelium, characteristic of " chronic desquamative nephritis." 
These casts are common in the urine of men who have had numerous 
attacks of gout, and they may often be detected long before any other 
sign of renal disease. Albumen appears at a later stage. 



Fig. 30. 




Fig. 31. 




Fig. 32. Waxy cast, sometimes deposited in the advanced stage ot 
chronic nephritis, but sometimes also in acute nephritis as a primary 
disease of the kidney. 

Fig. 33. Oily casts, composed of fibrine, entangling oil globules and 
epithelial cells gorged with oil. They indicate degeneration of the kid- 
ney, the most serious and incurable form of Blight's disease. 



Fig. 32. 



Fig. 33. 




Fig. 34. Purulent casts, composed of fibrine entangling pus cells, and 
indicating suppurative nephritis ; a very serious and often rapidly fatal 
form of disease. 

Fig. 35. Blood casts, such as occur in strangury and hasmaturia , 



138 



SYMPTOMS AND SIGNS OF DISEASE. 



after taking oil of turpentine. The blood is moulded in the kidney tubes, 
and affords unequivocal evidence that the haemorrhage was renal. The 
crystals attached to the cast are oxalate of lime. (The wood-cuts are 
from the drawings of Dr. George Johnson.) 



Fig. 34. 



Fig. 35. 





629. In diabetes, and in other morbid states in which the urine is 
loaded with matter in excess or foreign to its normal composition, we 
may wish to estimate the quantity of solid matter which it contains. 
This may be done by multiplying the excess of the specific gravity of 
the urine above that of water by the weight of the urine, and the pro- 
duct by 0*00233. By referring to a table in which the weight of solids 
in given quantities of urine of different specific gravities is stated, the 
amount of solids in the specimen under examination may be directly calcu- 
lated from the measured quantity, wdiich should be the whole amount 
passed in twenty-four hours, or a measured fraction of it. The first of 
the two tables given below presents the quantity of solid matter con- 
tained in 1000 grains of urine of different densities ; and the second the 
weight of one pint of urine. The mode of using these tables will be 
readily seen from a single example. Suppose a patient to pass, in twenty- 
four hours, three pints of urine of the specific gravity of 1*030, it is 
required to ascertain the weight of solid matter voided in this period. 
1000 grains of urine, specific gravity 1*030, contain by Table I. 69*90 
grains of solid matter, and a pint of urine of the same specific gravity 
w-eighs, by Table II., 9012 grains. Hence — 1 ^° " ■ or 629*9 grains 
is the quantity of solid matter contained in eacli pint of urine ; and 
629*9 x 3, or 1889*7 grains, is the total weight of solids voided in the 
twenty-four hours. This calculation gives a sufficiently close approxima- 
tion to the actual weight of saccharine matter incases of diabetes mellitus. 









TABLE I. 






Solids 


in 


1000 Grains of I 


Trine of different Densities. 


ific Gravity. 




Solids. 




Specific Gravity. 




Solids. 


1*001 


- 


2-33 




1*010 


- 


23-30 


1*002 


_ 


4-66 




1-011 


- 


25-63 


1*003 


_ 


6-99 




1-012 


- 


27-96 


1*004 


_ 


9-32 




1-013 


- 


30-29 


1 * 005 


_ 


11-65 




1*014 


- 


32-62 


1-006 


_ 


13*98 




1*015 


- 


34-95 


1-007 


_ 


16*31 




1*016 


- 


37*28 


1-008 


_ 


18-64 




1-017 


- 


39-61 


1*009 


- 


20-97 




1-018 


- 


41-94 



ABDOMEN AND ORGANS OF DIGESTION. 



139 



Specific Gravity 
1-019 




Solids. 
44-27 


Specific Gravity. 
1-035 


. 


Solids. 
81-55 


1*020 


- 


46-60 


1-036 


- 


83-88 


1-021 


- 


48-93 


1-037 


- 


86-21 


1-022 


_ 


51-26 


1-038 


- 


88-54 


1-023 


_ 


53-59 


1-039 


- 


90-87 


1-024 


- 


55-92 


1-040 


- 


93-20 


1-025 


_ 


58-25 


1-041 


- 


95-53 


1-026 


_ 


60 58 


1-042 


- 


97-86 


1-027 


- 


62-91 


1-043 


- 


100-19 


1-028 


- 


65-24 


1-044 


- 


102-52 


1-029 


- 


67-57 


1-045 


- 


104-85 


1-030 


- 


69-90 


1-046 


- 


107-18 


1-031 


- 


72-23 


1-047 


- 


109-51 


1-032 


- 


74-56 


1-048 


- 


111-84 


1-033 


- 


76-89 


1-049 


- 


114-17 


1-034 




79-22 

TABI 


1-050 
E II. 




116-50 


^Ye 


ght of a Pint of JJr 


ine of different Densities. 


Specific Gravity. 
1-010 


Wei 


ght of one Pint. 
8837 


Specific Gravity. 
1-031 


We 


ght of one Pint 
9021 


1-011 


- 


8846 


1-032 


_ 


9030 


1-012 


- 


8855 


1-033 


_ 


9038 


1-013 


- 


8863 


1-034 


_ 


9047 


1-014 


- 


8872 


1-035 


- 


9056 


1-015 


- 


8881 


1-036 


- 


9064 


1-016 


- 


8890 


1-037 


_ 


9073 


1-017 


- 


8898 


1-038 


_ 


9082 


1-018 


- 


8907 


1-039 


- 


9091 


1-019 


- 


8916 


1-040 


- 


9099 


1-020 


- 


8925 


1-041 


- 


9108 


1-021 


- 


8933 


1-042 


_ 


9117 


1-022 


- 


8942 


1-043 


_ 


9126 


1-023 


- 


8951 


1-044 


_ 


9134 


1-024 


- 


8960 


1-045 


_ 


9143 


1-025 


- 


8968 


1-046 


_ 


9152 


1-026 


- 


8977 


1-047 


_ 


9160 


1-027 


- 


8986 


1-048 


_ 


9169 


1-028 


- 


8995 


1-049 


- 


9178 


1-029 


- 


9003 


1-050 


_ 


9187 


1-030 


- 


9012 









2. The Abdomex and Organs of Digestion. 

630. The Abdomen. — To facilitate description, the chest and abdomen 
are divided into a number of distinct parts or regions by imaginary lines 
drawn from fixed points, as in Figs. 86 and 37. 

This division is made, in the first place, by four horizontal lines pass- 



140 



SYMPTOMS AMD SIGNS OF DISEASE. 



ing round the trunk of the body — the first (a a) at the level of the 
clavicles, the second (b b I at the level of the point of the ensiforcn car- 
tilage, the third [c c) at the level of the cartilages of the tenth ribs, and 
the fourth (d d) at the highest points of the crests of the ilia. The ab- 
domen is further subdivided into seven regions r three central and four 
lateral; by two vertical lines (e e) springing from the middle point of 
each groin, and meeting the horizontal line b b). 



Fig. 36. 



Fig. 37. 




The three central regions thus formed are named in the order from 
above to below, the epigastric, the umbilical, and the hypogastric ; the 
four lateral regions, taken in the same order, are the right and left hy- 
pochondriac, and the right and left iliac. The portion of the abdomen 
immediately above the line of* Pouparfs ligament is commonly known 
as the inguinal region. 

631. The organs situate in each of these regions are as follow : — The 
epigastric contains the middle portion of the stomach and the pylorus, 
the left lobe of the liver, the lobulus spigelii and hepatic vessels, and the 
head of the pancreas ; and behind these, the coeliac axis, the semilunar 
ganglion, and part of the vena cava, aorta, vena azygos, and thoracic 
duct. The umbilical contains the omentum and mesenteiy, the trans- 
verse portions of the duodenum and colon, and some convolutions of the 
jejunum. The hypogastric is occupied by the bladder and part of the 
small intestines. Behind the bladder is the uterus in the female, and 
the rectum in the male. The right hypochondriac contains the right 
lobe of the liver and the gall-bladder, part of the duodenum and ascend- 



EXAMINATION OF THE ABDOMEN. 141 

ing colon, the renal capsules, and part of the right kidney ; the left con 
tains the large end of the stomach, the narrow extremity of the pancreas, 
the spleen, part of the colon, the renal capsules, and upper part of the 
left kidney. The right iliac region contains the caecum, the termination 
of the ileum and the commencement of the colon ; the left, the sigmoid 
flexure and part of the descending colon. 

632. The posterior regions, formed by continuing the horizontal lines 
b b, c c, and d d, are divided by a vertical line following the course of 
the spine into four regions, the right and left dorsal, and the right and 
left lumbar. The right and left dorsal contain the upper portions of 
the kidneys. The right lumbar contains the caecum and lower part of 
the right kidney ; the left, the sigmoid flexure of the colon, and lower 
portion of the left kidney. 

633. When any of the organs are distended or enlarged, they encroach 
upon surrounding parts, and occupy adjoining regions. Thus, the dis- 
tended stomach or bladder may encroach on the umbilical region ; the 
distended colon may rise into the epigastric ; and the enlarged liver or 
spleen may descend into the right or left iliac. 

634. The size and shape of the abdomen vary with age and sex. In 
the child the abdomen is large ; in the spare adult, small ; in the female 
it presents an enlargement hi the hypogastric region. It varies in size, 
in the same person, with the full or empty state of the stomach, the 
quantity of gas in the intestines, and of urine in the bladder. Preg- 
nancy, ascites, ovarian dropsy, tympanites, hydatids, enlargement of the 
liver or spleen, and various morbid growths attached to the several 
organs, may also increase the size and alter the shape of the abdomen. 

635. In examining the abdomen, we employ three methods— inspec- 
tion, manual examination, and percussion. In certain cases we resort 
to measurement, and in a few instances to auscultation. 

636. By inspection, we ascertain the size, form, and movements of 
the abdomen. The size is increased by any of the causes just specified ; 
and the form is altered, either throughout the entire cavity, or in parts, 
according as the cause is extensive or limited. The history of changes 
of form is very important. Thus, the gradual, uniform, and central 
enlargement of pregnancy, the lateral enlargement in the first stage of 
ovarian dropsy, and the equal and gradual growth of ascites, form im- 
portant means of diagnosis. 

637. The movements of the abdominal parietes afford important in- 
dications, especially those of respiration. Thus, in peritoneal inflamma- 
tion, as well as in painful affections of the abdominal muscles, respiration 
is performed by the chest alone. On the other hand, in pleurisy and in 
painful states of the muscles of the chest or of the diaphragm, the re- 
spiration s performed chiefly by the muscles of the abdomen. Again, 
when the abdomen is greatly distended, the action of its muscles is nearly 
suspended and respiration is performed by the chest and diaphragm. In 



142 SYMPTOMS AND SIGNS OF DISEASE. 

extreme cases, the viscera are pressed against the diaphragm, and respi- 
ration is performed solely by the muscles of the chest. 

638. By the touch, we gain further information as to the size, form, 
shape, tension, and movements of the abdomen, including the movements 
of respiration. The pulsations of the aorta are also perceptible to the 
touch in cases of aneurism, of tumours situate over it, and of accumu- 
lations of faeces. We also ascertain by the touch the temperature and 
degree of sensibility of the abdomen. The temperature should be com- 
pared with that of other parts of the body. In acute peritonitis, and 
in severe febrile affections accompanied with abdominal inflammation, 
the surface is very hot, and has a peculiar pungency. 

639. In testing the sensibility of the abdomen, pressure should first 
be made gently, and with the open hand. If this gives pain, and 
inflammatory fever is present, the peritoneum is inflamed ; but if there 
is no fever, the seat of the pain may be inferred to be the muscular 
walls of the abdomen. If a slight touch produces no pain, we apply 
stronger pressure. If deep and moderately strong pressure occasions 
rather a feeling of soreness than of acute pain, we may conclude that 
inflammation of the mucous membrane of the stomach or intestines is 
present. The pain due to inflammation of the peritoneum is best deve- 
loped by a lateral pressure, causing the peritoneum to slide over the 
intestines. In colica pictonum, strong pressure relieves pain, and forms 
an important means of diagnosis. Muscular pain, also, is relieved by 
gentle pressure, gradually increased ; but, on the sudden removal of the 
hand, the muscles are thrown into action, attended by acute suffering. 
Muscular pain, too, is rarely accompanied by constitutional disturbance, 
and, like neuralgia of the skin, is often dependent on, or associated with, 
an irritable state of the spinal cord. The contraction of the muscles 
in the act of expiration is another cause of pain which must be distin- 
guished from the effect of pressure. 

640. In applying pressure to the abdomen, we should always mark 
the expression of the countenance, as this is much more to be depended 
on than the patient's answers, especially when typhous symptoms are 
present, or the brain is affected. When the abdomen is very tender, the 
patient will throw the muscles into rigid tension, so as to shield its con- 
tents from pressure ; and we have to suspend our examination till the 
patient's attention is diverted. When the tenderness is in the right 
hypochondriac region, and the cause disease of the liver, the right rectus 
muscle is generally found in a state of rigid contraction. 

641. If, in examining the abdomen, we discover a tumour, or are 
anxious to ascertain the state of any of its contents more exactly, we 
relax the muscles by placing the patient on the back, with the head 
slightly raised and bent forward, the arms extended by the sides, the 
thighs bent nearly at right angles on the trunk, the knees apart and 
turned outwards, and the feet resting on the bed in contact with each 
other. The patient must also be directed to use as little muscular effort 
as possible, and his attention must be diverted from the examination 



EXAMINATION OF THE ABDOMEN. 143 

which is going on. In this relaxed state of the abdominal parietes, the 
size and position of tumours, and the dimensions of the viscera, are readily 
ascertained. In women, a combination of abdominal swelling and ten- 
sion with extreme tenderness is sometimes met with, under the name 
of phantom tumours. The pain or pressure is so great as to prevent a 
complete examination ; but under the administration of chloroform the 
pain ceases, the abdominal walls become supple, and the work of examin- 
ation is rendered quite easy. 

642. Percussion may be performed either directly with the points ot 
the fingers, or by the intervention of a plate of ivory or wood, or of a 
finger of the left hand. Applied in this latter manner over the site of 
the stomach, or over any part of the small or large intestines containing 
air, it elicits a clear sound. In the epigastric region, in ordinary states 
of the stomach, and over any part of the intestines largely distended 
with aii', the sound is tympanitic. The clear sound is somewhat modi- 
fied if the air be mixed with fluid. Percussion, on the other hand, 
elicits a dull sound when applied over solid viscera, over collections of 
fluid, over hollow viscera when quite free from air, over the intestines 
when containing only fasces, over the enlarged liver or spleen, and over 
solid tumours. 

643. Percussion and the touch are employed together in detecting the 
presence of fluid. This is best done in the upright posture. The palm 
of one hand is placed on one side of the abdomen with a firm but gentle 
pressure, while the fingers of the other hand tap lightly and quickly on 
the part directly opposite to it. If fluid be present, a peculiar and cha- 
racteristic vibrating shock is experienced. 

644. Direct percussion with the points of the fingers is used to dis- 
tinguish muscular pains of the abdomen. A slight quick touch throws 
the muscles into action, and so causes pain. This, together with the 
absence of pain on firm pressure gradually applied, its recurrence oo the 
sudden removal of the pressure, the acute pain produced by every move- 
ment of the affected muscles, and the absence of urgent constitutional 
symptoms, combine to distinguish muscular pains from those due to 

. disease of deep-seated parts. 

645. Measurement of the abdomen is sometimes resorted to. A 
common tape graduated to eighths of an inch answers the purpose. No 
precautions are necessary beyond noting whether the measure is taken 
during inspiration or expiration. When the abdomen is uniformly en- 
larged by a tumour or collection of fluid, and especially when successive 
measurements are required, the tape should be applied at the level of 
the umbilicus. 

646. Auscultation is occasionally resorted to in examining the abdomen, 
to confirm, by means of the friction-sound, the diagnosis of peritoneal in- 
flammation. This sound is caused by the rubbing together of two 
surfaces roughened by deposits of lymph. By using the stethoscope, we 
may also hear the pulsations of the aorta in spare persons, and may 



144 



SYMPTOMS AXD SIGNS OF DISEASE. 



detect the placental murmur and the pulsations of the foetal heart. The 
first is a blowing sound, synchronous with the pulse of the mother, and 
best heard in the iliac regions near the groins. The second is a double 
sound, not unlike the ticking of a watch, occurring from 120 to 160 times 
in a minute, and best heard about the centre of the left iliac region. It 
is rarely audible till the end of the fifth month. 

In taking notes of cases of abdominal tumours or enlargement of viscera, 
their size and extent, as indicated by percussion, may be conveniently 
figured on outlines kept for the purpose. The figures annexed will serve 
to illustrate the use of such outlines. Fig. 38 shows the regions of dull 
and clear sound in the healthy subject, in which a shows the dull region 



Fig. 38. 



Ficr. 39. 




of the liver, and h that of the spleen ; while c indicates the region ot 
clear sound over the stomach moderately distended, and d that of the 
colon similarly distended. The fainter shadow (e) indicates the parts 
of the abdomen which, when empty, yield a moderately dull sound, 
when filled with flatus a clear (tympanitic) sound, and when filled with 
solid matters (as with faces) a full dull sound. Fig. 39 shows the dull 
region of the liver (a) extended, as in organic disease, with enlargement ; 
(&') a similar enlargement of the spleen, and the regions of dulness, cor- 
responding with a distended descending colon and rectum (/, ; a loaded 
caecum {g) ; and a distended bladder (h). The use of the shaded outlines, 
as applied to the heart and lungs, will be noticed in another place. 



examination of the chest. 145 

3. The Chest, and the Organs of Respiration and 
Circulation. 

647. An examination of the external conformation of the chest must 
precede all inquiries into the diseases of the parts contained within it. 
To facilitate such examination, the chest, like the abdomen, is divided 
into regions, by lines drawn from fixed points. (See figures, p. 140.) 
The two horizontal lines {a a in the line of the clavicles, and 6 6 on the 
level of the ensiform cartilage), joined by a vertical line bisecting the 
sternum, divide the chest anteriorly into two principal regions, of 
which certain parts are designated by characteristic names. Those 
beneath the clavicles are known as the subclavian regions, and those 
above them as the supra -clavicular regions. The parts marked by the 
nipples are called the mammary regions, and the armpits are known as 
the axillary regions. 

648. On the back of the chest the scapula]', inter- scapular, and infra- 
scapular, or superior dorsal regions, correspond — the first to the scapula 
of either side, the second to the space between the two, and the third to 
that part of the chest immediately below the angles of those bones. 

649. The size, shape, and movements of the chest may be ascertained 
by inspection, manual examination, and measurement. 

650. Inspection. — A well-formed chest is large in all its dimensions, 
and round in its outlines. The spine is straight, or, in very strong men, 
and those who use the right arm much, curved almost imperceptibly 
towards the right. The chest appears symmetrical ; but when measured, 
the right side is found to be larger than the left by about half an inch ; 
and there is naturally somewdiat more fullness above and immediately 
beneath the clavicle on the left than on the right side, from the left lung- 
rising higher than the right. The chest is wider and longer in men, but 
deeper in women. Women are also more subject to distortions of the 
chest and spine. 

651. A glance at the chest enables us to judge of its size. Closer 
examination is required to detect deviations from its usual form. The 
chief distortions affecting both sides alike, are thote arising from the use 
of stays in the female, and from constrained posture in the male. Of 
the latter, the most remarkable is the flattened chest of the shoemaker. 
Alterations in the shape of both sides of the chest also arise from diseases 
affecting equally both lungs; such as tubercles, leading to contraction^ 
especially in the subclavian region, and dilatation of the pulmonary cells 
(emphysema), causing a considerable enlargement about the middle of 
the chest. Alterations in the shape of one side, or of a limited portion 
of one side, may arise from more than one disease of the corresponding 
lung. Pleurisy, both acute and chronic, causes enlargement of the 
affected side ; but in certain chronic cases there is contraction. Jn hy- 
drothorax, also, and in pneumothorax, the size of the affected side is in- 
creased. When the dilatation is extreme, the intercostal spaces are raised 
to a level with the ribs. More partial changes arise from circumscribed 

L 



146 SYMPTOMS AND SIGNS OF DISEASE. 

pleurisy and limited adhesions. In advanced cases of phthisis, the position 
of a cavity is often indicated by the falling in of one of the intercostal 
spaces. Certain changes in the size and shape of the chest also arise from 
diseases of the heart and of the large vessels. 

652. Inspection also enables us to ascertain the character of the respi- 
ration ; whether tranquil or hurried, easy or difficult ; abdominal, as in 
acute pleurisy or acute pleurodyne, or thoracic, as in acute diseases of the 
abdomen and severe rheumatic affections of the abdominal muscles or 
diaphragm. The character of the heart's impulse may also be ascertained 
by inspection. 

658. Manual Examination. — By this, as by inspection, we ascertain 
the development of the muscles, the thickness of the parietes of the chest, 
the presence of oedema or emphysema of the integument-, heat and soreness 
of the skin, local tenderness, or muscular pain. The extent and character 
of the heart's impulses may also be ascertained by the hand and it is 
usual to apply the two hands to corresponding parts of the chest when 
we wish to compare the respiration on the two sides. 

654. The skin of the chest is preter naturally hot in inflammation of 
the lungs. 

655. Firm pressure in the intercostal spaces often causes pain when 
the pleura is inflamed, either generally or partially. This partial ten- 
derness occurs in consumption, when the pleura covering a cavity is in- 
flamed, or when a collection of pus is making its way externally. 

656. The chest is a common seat of muscular pains. Pain in the side 
(pleurodyne), is a consequence of violent efforts in coughing ; and pain 
in the left side is a very frequent occurrence in weak and delicate 
females. These muscular pains, which are apt to be mistaken for 
pleurisy, are developed by slight percussion with the points of the fingers, 
by the movements of the arms or trunk, and by a deep inspiration. The 
absence of pain on firm and gradual pressure, with its recurrence when 
the support is suddenly removed, is also a good diagnostic of muscular 
pain. Percussion with the fingers throws the muscles visibly into action 
through the whole length of their fibres, and causes remarkable partial 
and transverse contractions, which are best seen in emaciated persons, and 
especially in advanced cases of consumption. These partial contractions 
may also be excited in the biceps and in other large muscles. 

657. Measurement. — This may have to be resorted to in disease as a 
means of diagnosis ; in health, as a measure of strength and vigour. 

In disease we may wish to ascertain the size of the chest or of cer- 
tain portions of it, or to determine the degree of expansion and enlarge- 
ment which the w T hole, or parts of it, undergo during the act of inspi- 
ration. The progressive enlargement or diminution in its size which 
accompanies certain forms of disease, may also be ascertained by repeated 
measurements made with great care, in the same position, and in the 
same state of the cavity. A graduated tape may be used for this pur- 
] iose. To measure the size of the chest the tape should be carried hori- 
zontally round it, passing over the two nipples, or at an equal distance 



DIMENSIONS OF THE HEALTHY CHEST — THE LUXGS. 147 

above or below them. When the amount of expansion due to the move- 
ments of inspiration is to be ascertained, one end of the tape should be 
firmly held by one hand to the spine, while the other is allowed to slide 
freely through the other held over the centre of the sternum. The 
chest should first be measured after a full expiration, then after a deep 
inspiration : by shifting the tape we may measure the degree of expan- 
sion of both sides of the chest. In making these measurements the fact 
that the right side is naturally larger than the left by half an inch, 
must be borne in mind. The expansion of the chest in ordinary inspi- 
ration does not exceed an inch and a half, and it is somewhat greater on 
the right than on the left side. 

658. In examining the chest with a view to test the strength and 
vigour of healthy persons, as in recruiting for the army, we must be 
provided with certain standards of comparison, and also make allow- 
ance for the different degrees in which the muscles are developed, and 
the parietes clothed with fat. In these examinations the expansion of 
the chest in inspiration ought always to be noted. The act should be 
performed with evident ease and freedom ; and the tape drawn tightly 
across the nipples should show a movement of not less than an inch. 

659. The greatest circumference of the chest in robust men varies 
from 39 to 42 inches ; and in spare men of medium height ought not to 
fall much short of 35 inches. In robust men the circumference of the 
chest bears to the height the proportion of about 1 to 1 *75. If in a 
man of 5 feet 4 inches, the average circumference is taken at 38 inches, 
an allowance should be made of half an inch in the chest-measurement 
for every inch added to the^stature. 



Stature. 


Circumference of Chest. 


Stature. 


Circumference of Chest 


64 


38 


69 


40i 


65 


38} 


70 


41 


66 


39 


71 


. . 41} 


67 


39^ 


72 


42 


68 


40 


73 


42i 



660. It ought, however, to be understood, that the chests of very 
tall men are not so large in proportion to their height as those of men 
of medium stature. These taller men do not bear iatigue so well as 
those of shorter stature. 

661. A stethometer, or instrument for measuring inspirations, has 
been invented by Dr. Richard Quain. It consists of a string passing 
round the chest, adjusted in the act of expiration, and as the chest ex- 
pands by inspiration, indicating the enlargement by a hand moving on 
a dial-plate. Dr. Sibson employs a similar instrument, especially for 
measuring the movements of particular portions of the chest. 

The Luxgs. 

662. The cavity of the chest consists of a hollow cone, of which the 
apex is cut off by a horizontal plane, corresponding with its upper open- 



148 



SYMPTOMS AND SIGNS OF DISEASE. 



ing, and the base by an oblique plane, looking forwards and downwards, 
constituting the lower opening. The upper opening is filled by the 
trachea, oesophagus, and large blood-vessels : the lower is closed by the 
diaphragm. This conical cavity is flattened before where the cartilages 
of the ribs join the sternum, and behind, where the ribs unite with the 
spine : but it is rounded at the sides where it is formed by the ribs and 
their cartilages. 

663. The principal organs contained within the chest are the lungs 
and heart. The size of the chest corresponds closely with that of the 
lungs, and is liable to various deformities from diseases affecting those 

organs. The size and shape of the chest are also altered in certain 
diseases of the heart and large vessels. 

Fig. 40. 




664. The lungs are in close contact with the walls of the chest in 
every part, with the exception of a small space (2, Fig. 40; to the left 
of the sternum, where they leave part of the middle mediastinum con- 
taining the heart uncovered, and a narrow space (1) behind the sternum 
corresponding to the track of the large vessels. 

665. Of the two lungs the right is the larger, the left the longer, its 



NUMBER AND CHARACTER OF THE RESPIRATIONS. 149 

apex rising higher, and its base sinking lower. The right lung reaches 
to the level of the sixth rib in front, of the eighth rib at the side, and 
still lower behind. The left extends to the level of the seventh rib in 
front, it reaches the eighth rib at the side, and descends still lower be- 
hind. Both lungs applying themselves closely to the diaphragm, descend 
much lower behind than before, being there prolonged into thin wedges. 
The diaphragm separates them from the liver on the right side, from 
the stomach in the centre, and from the spleen and colon on the left 
side posteriorly. (Figs. 40, 41, and 42.) 

Fig. 41. 




666. The chest is subjected to several kinds ot examination, having 
special reference to the condition and functions of the lungs; our object 
being to ascertain, 1. The number and character of the respirations ; 
2. The capacity of the lungs ; and, 3. The true condition of their texture. 

667. Number and Character of the Respirations. — We may count the 
respirations in one of two ways: by observing the motions of the trunk, 
or of some article of clothing which moves as it moves, or by placing the 
hand on the chest or abdomen. The first method is best adapted to the 
sitting or erect, the last to the recumbent, posture. The most con- 



150 



SYMPTOMS AXD SIGNS OF DISEASE. 



venient plan is to cause the patient to lie down, to rest the hand on the 
abdomen, and then to grasp the wrist as if feeling the pulse. But 
whether we count the respirations by sight or by touch, the patient's 
attention should be withdrawn from the breathing, as the muscles of re- 
spiration are partially under the control of the will. The character of 
the respirations, whether natural, slow or quick, easy or laboured, sigh- 
ing, catching, or gasping, may be ascertained in either of these ways. 

Fig. 42. 




668. The character ot the respiratory movements differs in the two 
sexes and at different ages. In very young children they are performed 
chiefly by the abdomen ; in adults of both sexes mainly by the chest. In 
men the lower part of the chest, in women the upper part, is brought 
mostly into play, both in easy and in difficult breathing. 

669. In very tranquil breathing inspiration is performed by the de- 
scent of the diaphragm, marked by a gradual protrusion of the abdomen ; 
and expiration by contraction of the abdominal walls. In ordinary 
breathing, however, the ribs are raised and tilted outwards during inspi- 
ration, to recover themselves by their own elastic reaction during expira- 
tion. In violent inspiration, not only the diaphragm and intercostals 



CAPACITY OF THE LUNGS. 151 

are called into play, but the scapulae are raised and fixed. In violent 
expiration, as in coughing and sneezing, the abdominal muscles are 
brought into action, by which the viscera of the abdomen are compressed 
and the diaphragm forced upwards into the chest. Yawning and sigh- 
ing are forms of deep inspiration ; coughing and sneezing, of violent expi- 
ration. Deep inspirations relieve the circulation by leaving greater space 
for the admission of blood into the heart, whilst violent expirations free 
the lungs, nostrils, and air-passages of irritating substances. 

670. Number of Respirations.— These may be registered by an ap- 
propriate instrument. That which I devised for this purpose resembles 
a large watch with a dial-plate graduated to 1 0,000, and furnished with 
two hands, one of which is set in motion by a string attached to a short 
chain. The instrument is fastened over the pit of the stomach by a 
band passing round the abdomen, and the string is made tense in the 
act of expiration, by fastening the free end to any fixed point at a short 
distance from the body. Every act of inspiration accordingly, by bring- 
ing the two fixed points nearer together, relaxes the string, while every 
act of expiration tightens it and sets the hand in motion, causing it to 
traverse one space on the dial-plate. The experiments, of which the 
results are given under the head of the respiration, were performed 
by means of this instrument. 

671. Capacity of the Lungs. — Two plans have been proposed fo/ as- 
certaining the capacity of the lungs ; the one by Dr. Lyons, the other by 
Mr. Abernethy. The latter plan was employed by Mr. Thackrah, of 
Leeds, and, with some modification, by Dr. Pereira, and was afterwards 
much improved by Dr. Hutchinson. A portable spirometer is also in 
use, invented by Mr. Coxeter. 

672. Dr. Lyons' method consists in noting the time required to empty 
the chast after a complete inspiration, by counting aloud. To render the 
expiration continuous and complete, the patient is directed to count from 
' one ' upwards, as far as he can, slowly and audibly ; and the number 
of seconds is noted by the watch. The time so occupied is a measure 
of the capacity of the lungs. Dr. Lyons fixed its limit for perfectly healthy 
persons at thirty-five seconds : but this is too low ; for in more than one 
trial I have myself continued to count for forty seconds. In confirmed 
phthisis, Dr. Lyons stated the limit at eight, and often at less than six 
seconds ; and, in pleurisy and pneumonia, from four to nine. This method, 
though open to obvious objections, admits of useful application. 

673. Abernethy's method consists in making the patient take a deep 
breath, and then causing him to expire through a bent tube into an in- 
verted jar full of water. The water displaced measures the capacity of 
the lungs. A healthy person with sound lungs can displace six or eight 
pints. If the quantity displaced is much less than this, we infer that the 
lungs are diseased, or compressed. ' Muscular debility or spasm, may 
occasionally make the result doubtful, yet, in general, I believe it will 
afford useful information.' 

674. This method was also employed by Mr. Thackrah, of Leeds, who 



152 



SYMPTOMS AND SIGNS OF DISEASE. 



suggested its use in examining recruits. Nineteen officers and sold. 
of the 14th Light Dragoons were found to hare a chest capacity of from 
220 to 295 cubic inches ; the majority expiring from 24(J to 250. In 
tailors the mean was 221, and in shoemakers 182 cubic inches. 

675. Dr. Hutchinson im- 
proved this rude method by 
substituting for the jar con- 
taining water a gasometer 
propel ly poised and accu- 
rately adjusted. As his in- 
strument is now used in 
some Assurance Offices, and 
is believed to afford useful 
indications in some cases of 
early chest affection, a wood- 
cut, with a short descrip- 
tion, is here introduced. 

The instrument consists 
of a cylindrical vessel, c, hold- 
in g several pints of water, 
filled by a spout at the top, 
and emptied by a stop-cock, 
f, at the bottom. Into this 
vessel a cylinder, c\ of smal- 
ler size, counterpoised with 
the weights, w w, is inverted. 
The cover of this vessel has 
an opening, e and e, in the 
centre, which may be closed 
at will by the plug. cV and d. 
An elastic tube, a, with a 
glass mouth-piece, and fur- 
nished with a stop-cock, b, 
commun i cates w i th the lower 
vessel, c. The bent glass 
tube, g, also communicates 
with the lower vessel, as 
does the glazed space, i. A 
graduated scale, s" and s. 
attached to, and moving 
with, the upper vessel, c v , 
and an index, h. complete 
the instrument. If we sup- 
pose the gasometer. c\ to be filled with air. so as to occupy the position 
indicated by the dotted lines, the instrument is prepared for use by 
taking out "the plug, d, and lowering the gasometer till the coloured 
spiriMn the two legs of the syphon, a. stands at the same level. The 
index, h, is then placed at the level of the water in the glazed space, «", 





CAPACITY OF THE CHEST — THE SPIROMETER. 153 

which, communicating!: with the reservoir, e, shows the height of the 
water within, and at the zero of the scale. The plug, d, is now replaced, 
the stop-cock, b, being supposed to remain closed. The subject of the 
experiment then fills his chest completely, and applying his mouth to 
the mouth-piece, and at the same time opening the stop-cock, 6, dis- 
charges the air from his lungs. The gasometer rises, the stop-cock, b, 
is again turned so as to close the passage for air, the coloured liquid in 
the syphon, g, is again brought to the level in the two legs, and the 
height of the scale above the index marks the number of cubic inches, 
and measures, if the experiment has been properly performed, the capa- 
city of the lungs, or, to speak more correctly, * the quantity of air which 
an individual can force out of his chest by the greatest voluntary expi- 
ration, after the greatest voluntary inspiration.' 

676. By numerous observations made with this instrument, Dr. Hut- 
chinson established certain averages for the healthy chest, which he then 
used as standards of comparison for the chests of consumptive patients. 
He found the limits of capacity in health to be 80 cubic inches in a 
dwarf measuring 3 feet 9 inches, and 464 cubic inches in a giant mea- 
suring 6 feet 11 J inches. He also ascertained that the capacity was 40 
or 50 cubic inches below the mean in very fat persons ; that it was re- 
duced from 4 to 6 inches by a moderate meal, and from 9 to 14 by a 
full meal ; that it is greatest in the erect posture ; that it diminishes 
after 55 years of age; that it bears a remarkable relation to the stature; 
and that it is much diminished in pulmonary consumption. 

677. The following table presents in the first column the ascertained 
or calculated capacity of the lungs in healthy persons between the ages of 
15 and 55, of different statures, from 5 to 6 feet; and in the second and 
third columns the capacity of the lungs of persons of the same stature, 
suffering from the early and advanced stages of pulmonary consumption. 
(The table is taken from Dr. Hutchinson's work on the Spirometer.) 



Statuve. 


Capacity. 


Early Stage of 


Advanced Stage 




Healthy Males. 


Consumption. 


of Consumption. 


'eet. Inches. 


Cubic Inches. 


Cubic Inches. 


Cubic Inches. 


5 1 


174 


117 


82 


5 2 


182 


122 


86 


5 3 


190 


127 


89 


5 4 


198 


133 


93 


5 5 


206 


138 


97 


5 6 


214 


143 


100 


5 7 


222 


149 


104 


5 8 


230 


154 


108 


5 9 


238 


159 


112 


5 10 


246 


165 


116 


5 11 


254 


170 


119 


6 


262 


176 


123 



678. The disparity shown between the capacity of the lungs in healthy 
persons, and in persons of the same stature under incipient and advanced 



154 SYMPTOMS AXD SIGNS OF DISEASE. 

consumption, is so considerable as to prove the utility of this instrument. 
But it must be borne in mind that emphysema and bronchitis, as well 
as diseases of the heart encroaching on the lungs, would give rise to the 
same results. In making practical application of the figures it would 
probably be unsafe to set down to the account of disease a moderate di- 
minution of capacity ; though Dr. Hutchinson thought that if a man 
between 5 feet 7 and 5 feet 8 inches, who ought to expel about 220 
cubic inches of air, can expel no more than 185, or a 6-foot man, who 
ought to expel about 260 cubic inches, no more than 200 or 220 cubic 
inches, disease may be suspected. When we bear in mind the modifi- 
cations in the capacity of the lungs due to the causes specified in § 676, 
and especially that, according to Dr. Hutchinson's statement, ' very fat 
men, of any stature, may blow 40 or 50 cubic inches less than the 
mean, and yet not be diseased in the chest,' it is but reasonable to sup- 
pose that other causes compatible with health may lessen its capacity. 
The figures in the second column are, however, so much below those 
belonging to the healthy chest, as to furnish a very strong presumption 
of disease. 

679. In using Dr. Hutchinson's instrument, the patient should be in 
the erect posture, and be narrowly watched to see that he performs the 
operation of expanding his chest and expelling the air carefully and pro- 
perly. Allowance must also be made for advance in age above 55. 

680. Dr. Hutchinson also made numerous observations, with an in- 
strument of his own invention, on the force with which the muscles of 
inspiration and expiration draw in and expel air through the nostrils. 
But these experiments have obviously no very important practical bearing. 

681. The instrument invented by Mr. Coxeter has the advantage of 
being simple, portable, and cheap, and in the hands of a practised per- 
son, using it always in the same way, would afford useful indications. 
It consists of two flexible, inelastic, and air-tight bags — one large, the 
other small — connected by a tube fitted with a stop- cock. The larger 
bag has a second stop-cock fitted with a glass mouth-piece ; and the 
smaller bag, which is graduated to 50 cubic inches, has also a second 
stop-cock. In using this instrument we close the stop-cock between the 
two bags, and open that fitted with the mouth-piece, through which the 
patient, having taken a deep inspiration, discharges the contents of the 
chest into the larger bag, and closes the stop-cock to which the mouth- 
piece is attached. The smaller bag being empty, and its terminal stop- 
cock closed, the central stop- cock is opened, and the bag filled with air. 
The central stop-cock is again closed and the terminal one opened, so as 
to allow the contents of the small bag to be expelled. This done, the 
same process is repeated till all the air contained in the larger bag has 
been transferred to the smaller one and measured off. As the results 
obtained differ little from those yielded by Hutchinson's spirometer, the 
figures of the last table may be used as standards of comparison for both 
instruments. 

682. The Texture of the Lungs. — To ascertain the state of the tex- 






PERCUSSION AND AUSCULTATION. 155 

ture of the lungs, we use the two methods known as percussion and aus- 
cultation. 

683. Percussion and Auscultation. — The ear is employed in two 
ways in examining the lungs, — in listening to the sounds caused by 
striking the walls of the cavity, and in listening to those produced by 
the passage of air through the lungs, and by the movements which take 
place between the lungs and the chest. Both these modes of examina- 
tion are comprised in the meaning of the term auscultation ; but it is 
usual to call the first percussion, and the second auscultation, 

684. Percussion. — If the chest were full of air, it would yield, when 
struck, a sound like that of an empty barrel or drum ; if, on the con- 
trary, it were filled with solid animal substance, it would sound as dull 
as the arm or thigh. But containing, as it' does, a spongy organ, the 
lung, including in its tissue a large quantity of air, it yields, when 
struck, a hollow sound, but one less hollow than that which it would 
give if containing only air. The more air it contains, the more hollow 
the sound ; hence it is clearer during inspiration than during expiration. 
If, again, the texture of the lung be so altered as to admit a larger quan- 
tity of air, as in emphysema, the chest yields a clearer sound. On the 
other hand, if the lung admits less air than usual, the sound becomes 
more dull : this happens in congestion, in inflammation, in tubercular 
deposit ; when solid tumours form in the lung itself, or occupy its place ; 
as also when the lung is compressed by fluids collected in the sac of the 
pleura (hydrothorax and empyema). But if, instead of fluid, there is 
air in the cavity of the pleura (pneumothorax), the sound is more hollow 
than if the healthy luug were in contact with the walls of the chest. 

685. But the nature of the sound is also influenced by the thickness 
of the walls of the chest itself. If two chests contain exactly the same 
quantity of air, that will give the clearest sound which has the thinnest? 
walls. Those parts of the chests too, which are padded with muscle or 
fat, yield a duller sound than those which are less covered with muscle. 
Thus, the sound is dull over the pectoral muscles and over the shoulders ; 
but clear above and below the clavicles, in the arm-pits, and below the 
angles of the scapulae. In the healthy chest, then, the clearness of the 
sound will vary directly as the quantity of lung beneath the part struck, 
and inversely as the thickness of the parietes. 

686. Again, wherever the substance of the lung is thin, the sound on 
percussion is modified by the parts lying immediately behind it : thus, 
below the fourth rib, the layer of lung in front of the liver on the right 
side is thin ; and the sound is less clear than in the upper part of the 
chest. The thin layer of lung which overlays the heart, so as to leave 
only a small portion of it uncovered (2, Fig. 40), has the same effect. 
In all such cases, gentle percussion elicits the clear sound of the healthy 
lung, strong percussion that of the solid substance behind it. The limits 
of the clear sound are somewhat extended by a deep inspiration, which 
stretches and expands the lungs, and diminished by a forcible expiration, 
which contracts them. Tumours in the deeper seated parts of the lung, 



156 SYMPTOMS AND SIGNS OF DISEASE. 

or consolidation of the lung itself, have the same effect as a solid viscus. 
Gentle percussion elicits the clear sound of the healthy lung, and strong 
percussion the dull sound of the tumour or condensed lung beneath. 
The clearer sound of the healthy lung is exaggerated in the parts of the 
chest near the stomach by the gas contained in that organ. 

687. When the chest is being examined^ the patient should be in the 
erector sitting posture, and, if possible, in an open room, for curtains and 
bed-clothes dull the sound. The chest should be bare, but in females it 
may be covered by a single layer of clothing. Each part of the chest 
under examination should be rendered as tense as possible ; the anterior 
part by stretching the neck and tin owing back the shoulders ; the supra- 
clavicular space by turning the neck to the opposite side; the axilla?, by 
raising the arms above the head ; and the back part by causing the 
patient to fold his arms and stoop. In comparing opposite and corre- 
sponding points, the position of both sides must be the same. If we are 
examining the front of the chest, the hands must fall loosely ; if the 
sides, they must be raised equally above the head ; if the back, they 
must be equally folded. 

688. There are different ways of eliciting the sounds of the chest by 
percussion. We may strike with the points of the fingers, with the flat 
of the hand, or with the fist, or we may interpose the fingers of the 
opposite hand, or a pad of India-rubber, or a plate of wood or ivory. 
Such things are called " plessimeters," and percussion by their aid is 
named " mediate percussion." When we are dealing with slight dif- 
ferences of sound, it is advantageous to use a plessimeter combined with 
a hammer in such a way as always to strike with the same force. Dr. 
Sibson makes use of this combination under the name of a " spring ples- 
simeter," consisting of a round pad of India-rubber fixed to the end of 
an axis, and striking on a plate of ivory. The axis works through a 
collar, and, being raised, is made to fall each time with equal force by 
means of elastic springs. 

689. Direct percu c sion with the points of the fingers should only be 
employed to set the muscles in action, for in many cases, especially in 
advanced phthisis pulmonalis, the skin and muscles are so sensitive that 
the slightest touch occasions pain. Percussion with the open hand, or 
closed fist, is little used, except as a means of contrasting the two sides 
of the chest over their whole extent at once. 

690. Mediate percussion is always to be preferred, and the readiest 
plessimeter is a finger of the left hand applied to the surface with a firm 
pressure, by which the skin and flesh are condensed, and made better con- 
ductors of sound. This is especially necessary in stout, flabby, dropsical, or 
emphysematous subjects. The finger should then be sharply struck by the 
three middle fingers of the right hand, taking care that the stroke falls 
directly and not obliquely. In comparing the two sides of the chest, 
care should be taken to strike the same point, with the same force, and 
in the same state of the chest, whether full of air in inspiration, or partly 
emptied by expiration, or motionless as when the breath is held. 



AUSCULTATION. 



157 



691. The chief indications given by percussion in disease, by clear and 
dull sounds respectively, are shown in the following table : — 



Clear Sound 

on 
Percussion. 



! ! 



In the Lungs. 
Healthy condition. 
Emphysema. 
Tubercular excavation. 



t Congestion, hepatization, and 
condensation. 
Dull Sound Pulmonary apoplexy. 

on -{ (Edema. 

Percussion. I Tubercular deposit. 

! Other morbid degenera- 

' t.inns. 



External to the Lungs. 
Pneumothorax. 



Pleuritic effusion. 

Hydrothorax. 

Hasmathorax. 

Tumours in pleura or media- 
stinum. 

Diseases of heart or arteries, with 
enlargement. 



692. From the part of the chest in which the clear or dull sound occurs, 
we may often infer the cause which produces it. Thus, emphysema, 
though it may be confined to one side, and to a limited spot, commonly 
occurs on both sides of the chest, and over a large extent of lung ; pneu- 
mothorax, on the contrary, is usually confined to one side, and tubercular 
excavations generally to the upper part of the lungs. 

693. Congestion and hepatization of the lungs occupy chiefly the lower 
lobes, generally on one side, but sometimes on both ; oedema commonly 
exists in both lungs at the same time ; tubercular deposit is found 
chiefly in the upper lobes : whilst other morbid degenerations occupy all 
parts of the lungs indifferently. Of causes external to the lungs, effusion 
of blood or pus into the cavity of the pleura is commonly confined to one 
side ; hydrothorax usually extends to both ; tumours in the pleura and 
mediastina may occupy any position ; diseases of the heart affect the 
neighbouring parts ; and aneurismal tumours chiefly the upper and an- 
terior part of the chest. 

694. Auscultation. — The passage of air through the structures of the 
lungs, in inspiration and expiration, causes certain sounds, which are 
heard on applying the ear or the stethoscope to the chest, and are found 
to vary in different situations. In the neck, and at the upper part of 
the sternum during inspiration, a hollow, blowing sound is heard — this 
is tracheal respiration ; on each side of the upper part of the sternum, 
between the scapulas, and sometimes in the axillae, a whiffing tubular 
sound — this is bronchial respiration ; on most other parts of the chest a 
sound which has been compared to that of a sleeper breathing gentlv 
through the nostrils, or to the sighing of a gentle breeze — this is called 
vesicular, from its presumed seat, the air-cells. This sound is heard both 
in inspiration and expiration ; but the expiratory murmur is less distinct 
and shorter. When, as in children, this breezy murmur is very distinct, 
it is termed puerile respiration. 

695. The intensity of this respiratory murmur varies in different 
healthy persons, and in the same person at different times. It is more 
intense, as has just been stated, in young children and in females. It is 
also augmented by deep inspiration, and, therefore, may be increased by 



158 SYMPTOMS AND SIGNS OF DISEASE. 

causing the patient to breathe quick, to draw a deep breath, or to cough, 
whereby the lungs are emptied, and a full inspiration secured. The 
respiratory murmur also becomes more intense, or puerile, in one part 
of the lung by consolidation of the remainder, and in one lung by con- 
solidation of the other ; also by partial impediments to free action of the 
lung, such as tight stays in women. 

696. The respiratory murmur is sometimes scarcely audible ; but in 
the absence of other morbid sounds, and of dullness on percussion, this 
indistinctness does not indicate disease. 

697. The respiratory murmur may also be absent in limited portions 
of the chest, through the bronchial tubes being obstructed by tenacious 
mucus ; but here percussion will give a clear sound, or it may be absent, 
because the air-cells are filled with fluid from within ; or compressed 
from without, when the chest will sound dull on percussion, unless the 
pressure be occasioned by air in the pleura. 

698. The bronchial respiration in health is heard along the track of 
the large bronchial tubes ; but if the lung be condensed, it not only 
loses its proper respiratory murmur, but, being a better conductor, con- 
veys to the ear the sound produced in the tubes. Hence, bronchial 
respiration heard with unusual distinctness near the site of these tubes, 
or heard on one side and not on the other, or with widely-differing in- 
tensity on the two sides, or in parts where it is not heard in health, is 
an indication of consolidation by disease or pressure. 

699. The bronchial respiration, as thus heard, resembles intense 
puerile respiration ; or the noise made by drawing the breath through 
the closed hand ; or that occasioned by blowing into a quill ; or, lastly, 
the short puff used in blowing out a candle. 

700. To the same class of sounds belongs the cavernous respiration, 
which, in its most marked form, produces a perfect illusion of air drawn 
through the stethoscope during inspiration, and puffed into the ear 
during expiration. It generally arises from a dilated bronchus, but 
occasionally from a cavity in the substance of the lung. 

701. The amphoric respiration is the sound produced by blowing into 
a bottle, and is caused by the passage of air into a cavity lined with a 
dense membrane. 

702. Besides the respiratory sounds produced in the tubes and air- 
cells of the lungs, when those parts are moistened by their natural se- 
cretions in their usual quantity, there are other sounds due to the 
increased resistance offered to the passage of air by constriction of the 
parts themselves, or by fluids of various degrees of consistence. 

703. The variation in character and intensity of these sounds is in- 
dicated by the terms rale (rattling), rhonchus (snoring), crepitation 
(crackling), and sibilus (hissing, wheezing, or whistling). Crepitations 
are further distinguished as dry and moist — the dry being due to swollen 



RHONCHUS AXD SIBILUS. 159 

mucous membrane, constriction of the tubes, or obstruction with viscid 
phlegm ; the moist to fluids of less consistence in the tubes or cells. 

704. Rales are limited to the larynx, trachea, and bronchial tubes ; 
Ehonchus and Sibilus to the largest and medium-sized tubes ; and Crepi- 
tation to the fine-air tubes and the air-cells. 

705. Crepitation is of two kinds — fine and coarse. Fine crepitation 
has its seat in the air-cells and smallest air-tubes ; it is a very delicate 
sound, resembling that caused by rolling a lock of hair between the 
thumb and finger. Coarse crepitation is heard in the finer and medium- 
sized tubes, and is nothing more than fine mucous rale. 

706. Crepitation is further subdivided into moist and dry. Moist 
crepitation {rale crepitant of Laennec) is a rapid succession of crackles, 
such as are produced by throwing salt on a hot iron plate. The sensa- 
tion may he felt by compressing healthy lung tissue, or emphysematous 
integument. It exists whenever the finer bronchi and air-cells, partially 
filled with viscid fluid, still admit the passage of air. Hence it is 
present in oedema and apoplexy of the lungs ; occasionally in pulmonary 
catarrh and bronchitis ; often in the first stage of phthisis ; and in the 
first stage of pneumonia, as its most constant and characteristic sign. 
It disappears when hepatization comes on, and reappears when the in- 
flammation is subsiding, and the lung begins to assume its healthy con- 
dition. In the first, and last of these stages the moist crepitant rhonchus 
obscures the respiratory sound, but does not completely mask it ; in the 
stage of hepatization, both sounds are absent. 

707. Dry crepitation. (Bale crepitant sec a grosses bulks, or cra- 
quement of Laennec.) This is the sound produced by blowing into a dry 
bladder. It occurs during inspiration in emphysema, and most distinctly 
in interlobular emphysema. 

708. Ehonchus and Sibilus. — These sounds are indicative of a dry 
state of the mucous membrane. They generally occur together as sibi- 
lant rhonchus, which resembles a prolonged whistle, the chirping of 
birds, or the sound emitted on the separation of two smooth oiled sur- 
faces. The sonorous resembles the snore of sleep, the bass note of a 
violoncello, or the cooing of a pigeon. When intense, it may be perceived 
by the hand placed on the chest. All these varieties of sound arise from 
contraction of a portion of bronchial tube, by swelling of the mucous 
membrane, by pressure of consolidated lung, or by a plug of tenacious 
mucus, the sibilant rhonchus existing in the smaller, and the sonorous 
in the larger tubes. A click is also sometimes heard, either during in- 
spiration or expiration, from the sudden displacement of a portion of 
viscid mucus. 

709. The moist bronchial rhonchus is called the mucous rale [rale 
muqueux of Laennec). It is due to the passage of air through tubes 
containing a fluid, and is the sound caused by blowing through a pipe 
into soap and water. It is present in pulmonary catarrh, bronchitis, and 
haemoptysis ; and in all diseases accompanied with much expectoration, 



160 SYMPTOMS AND SIGNS OF DISEASE. 

as in the third stage of pneumonia, and in phthisis. The tracheal i ale 
is a mere modification of this sound, existing in the trachea when filled 
with fluid. It has been compared by Laennec to the rolling of a drum 
at a distance, or the noise of a carriage in a paved street. The cavernous 
rhonchus occurs in empty cavities of the lung, and is extremely rare. 
It is caused by the bubbling or gurgling of a fluid in a circumscribed 
space, and is, therefore, a sure sign of a cavity in the lungs, which, in 
ninety-nine cases out of a hundred, is of tuberculous origin. 

710. Vocal Sounds. — In a healthy chest there is commonly a dif- 
fused resonance, most distinct between the scapulas, in the situation of 
the bronchial tubes. If we place the hand on the chest in the act of 
speaking, especially if the voice be a bass, we perceive a vibration, or 
fremitus. If we place the stethoscope over the larynx or trachea, the 
voice seems to pass through the tube, being much more clearly perceived 
by the ear applied to the stethoscope than by the other. This is laryn- 
gophony. A similar sound is heard when the lungs between the bron- 
chial tubes and the walls of the chest are condensed, and especially if the 
bronchi are at the same time enlarged. This is brorochophony . Jf in 
the cavity of the pleura, external to a condensed lung, there is a thin 
layer of fluid, as happens in recent cases of pleurisy, a sound is heard 
like the bleating of a goat, or the squeaking of Punch. This is ago- 
phony. Again, in cases of pulmonary excavation,- the sound of the voice 
passes through the tube to the ear, as it does in la/yngophony, and is 
called pectoriloquy. Lastly, w T hen there is a large cavity communicating 
with the bronchi, containing fluid and filled with air, a sound is pro- 
duced during respiration, by speaking, or in coughing, which resembles 
either the falling of a pin into a cup, or that caused by blowing quickly 
and forcibly into a bottle with a narrow neck. The first is called metallic 
tinkling, the second amphoric resonance or buzzing. These sounds are 
heard most distinctly in pneumothorax ; but they also occur in large 
abscesses of the lungs. In very rare cases of pneumothorax this metallic 
tinkling has been produced by each beat of the heart. 

711. There is one sound, which, though due to an external cause, may 
be confounded by the beginner with sounds originating within the chest 
— the muscular sound (bruit musculaire). It is due to muscular con- 
traction, and is very distinct in patients shivering w T ith cold, or in w T hom 
the muscles are put on the stretch. When the neck and shoulders are 
forcibly thrown back, the hands forcibly raised above the head, or the 
arms strongly folded across the chest, this sound is very distinct, it is 
an extremely rapid vibrating sound, bearing a close resemblance, when 
strongly marked, to the distant rumbling of carriages over a paved stieet. 
The pupil should make himself familiar with it, by placing his ear on 
the pillow, and contracting the muscles of the jaw with different degrees 
of force and quickness, taking care, at the same time, to avoid grating 
the teeth. When he closes the jaw gently, he will hear the rapid vibra- 
tion just mentioned ; a stronger contraction will render the vibration 
more rapid ; a strong and abrupt contraction closely imitates the first 
sound of the heart ; a still stronger and quicker one produces a sound 



EESPIRATOKY AND VOCAL SOUNDS. 161 

which might be confounded with the " bruit de soufflet," and the strongest 
and most abrupt contraction causes a species of cooing sound. The ear 
applied to the biceps muscle during strong contraction, or to the abdo- 
minal muscles during a violent and abrupt expiratory effort, perceives a 
sound not easily distinguished from the first sound of the heart. The 
continuity of the " bruit musculaire " distinguishes it at once from all 
the respiratory and vocal sounds. 

712. It only remains to mention two sounds which have their source 
external to the lungs, in the sac of the pleura. The one is & friction or 
to-and-fro sound, occurring both in inspiration and expiration when the 
pleurae are dry and rough with deposits; the other a splashing sound, 
distinctly heard by the ear applied to the chest, when there is a mixed 
collection of air and fluid in the pleural cavity, and a sudden jerk (suc- 
cussiun) is given to the chest. This sound is sometimes heard in very 
large tubeiculous cavities. 

713. The young auscultator may consult with advantage the follow- 
ing table, which pi esents at one view the chief points just stated. 

SOUNDS PRODUCED BY THE PASSAGE OF THE AIR IN RESPIRATION. 



Tracheal ; in the neck and at the top of the sternum. 

Bronchial ; near the top of the sternum, and between the scapulae. 

Vesicular ; on most other parts of the chest. 

MORBID. 

Bronchial Respiration ; from condensed lung. 

A ~ i . '[in cavities communicating with the bronchi. 

Amphoric; j ° 

I Mucous; liquid in bronchi. 
Moist. (.Crepitation ; viscid liquid in small tubes and air-cells. 
( Gurgling ; liquid in cavity. 

iDry crepitation ; in emphysema. 
Cavernous rhonchus ; in cavity destitute of fluid. 
„./., , , I Contraction of bronchi, bv swell- 

Simlant and I . £ / J 

a i 7 < mg or mucous membrane, pies- 

Sonorous rhonchus. j ° , t .' r 

[ sure, or tenacious secretion. 



SOUNDS OP THE VOICE TRANSMITTED THROUGH THE CHEST. 

^ ( Laryngophony ; over larynx. 

•5 I Tracheophony ; over neck and upper part of sternum. 
"§ j Bronchophony ; near top of sternum, between the scapulas, &e. 
W ( (Fremitus, or vocal vibration ; felt by hand in many parts of chest.) 
\ Bronchophony ; sound of voice through condensed lung. 
j JEgophony ; the same, vibrating through a thin layer of fluid. 
Pectoriloquy ; the same in a cavity of the lungs. 
Tinkling, 4"°' ? a changed echo of voice or cough in a large cavity 
containing air and liquid. 



162 SYMPTOMS AND SIGNS OF DISEASE. 

SOUNDS PRODUCED BY THE MOTIONS OF THE LUNGS. 

Friction-sounds, when the pleura are dry or rough from deposit. 

SOUND PRODUCED BY SUCCUSSION. 

A splashing sound, when the cavity of the pleura or a large tubercu- 
lous cavity contains fluid mixed with air. 

SOUNDS PRODUCED BY THE CONTRACTION OF THE MUSCLES. 

Vibratory sounds of varying intensity. 

The Heart. 

714. The position of the heart and large vessels, with their relation 
to the walls of the chest, and to the lungs, will be best understood by 
referring to Figs. 40 and 41. It will be seen that the lungs, which 
fill so large a part of the chest, leave an irregular space (1 and 2, Fig. 
40 1 in the anterior part of the chest unoccupied. That part of this 
space (1; which lies behind the upper half of the sternum, is of a nearly 
uniform width of two inches, the anterior edges of the two lungs being 
here nearly parallel. The lower portion of this space (2), on the other 
hand, being formed by the wide separation of the left lung from the 
right, approaches the triangular form. The upper part of this space 
corresponds to the large vessels, the lower to the heart. This space, 
however, does not represent the size and shape of the heart and large 
vessels, but merely of such portions of them as are not concealed from 
view by the thin edges of the lungs; nor can the heart and large ves- 
sels be fully seen until the pericardium has been opened, the cellular 
membrane connected with it dissected away, and the lungs turned aside 
to the right and left. Posteriorly (Fig. 38), the inner edges of the two 
lungs are nearly parallel, leaving a centre space (1 and 2) about two 
inches wide, occupied by the trachea and oesophagus above, and by the 
(esophagus and descending aorta below. In consequence of the great 
thickness of the spine and muscles of the back, this space is not favour- 
able to stethoscopic examination. 

715. The pericardium, w 7 hich surrounds the heart, is firmly attached 
above to the large vessels connected with its base, and to the diaphragm 
below ; so that the heart beats within this fibro-serous sac, subject to be 
pulled down with it when the diaphragm descends in inspiration, and 
to be raised with it when the diaphragm moves upwards in expiration. 

716. But as the large vessels, firmly bound to each other and to sur- 
rounding parts, spring from the base of the heart, and as the short as- 
cending cava connects this part with the tendinous portion of the dia- 
phragm, it is not subject, in healthy persons, to any material alteration 
of position. 

717. The large vessels, therefore, form a sort of fixed point on which 
the heart moves. From this point it is tilted and twisted forward 



POSITION OF THE HEART. 163 

during the contraction of the ventricles ; towards this point it is raised 
with the diaphragm, during expiration ; and from this point it is pulled 
downwards during inspiration. These changes of place are exaggerated 
by the ribs moving in opposite directions to the diaphragm. 

718. The change of place due to inspiration and expiration is so 
great, that, during a deep inspiration, the apex of the heart, instead of 
beating in the fifth intercostal space, may be felt in the sixth, but in- 
distinctly, from the lung being drawn in front of it. By a forced expi- 
ration, on the other hand, the ribs are drawn down and brought closer 
into contact with the heart, so that it may be felt beating in the fourth 
intercostal space, and even as high as the third rib. 

719. The same act of inspiration which depresses the diaphragm and 
tilts the ribs outwards expands the lungs, so that their anterior edges 
slide over the pericardium ; and the same act of expiration which forces 
the diaphragm upwards, and pulls the ribs downwards, causes the lungs 
to collapse, and their anterior edges to slide back again, thus leaving 
more of the pericardium exposed. A distended stomach, or a general 
enlargement of the abdomen, has the same effect on the position of the 
heart as an act of expiration. 

720. In consequence of the free motion which the heart enjoys, it is 
affected by the posture of the body, receding a little from the anterior 
walls of the chest when we lie on the back, and moving somewhat to 
the right or left, as we lie on the sides. 

721. The heart, then, occupies an oblique position within the chest, 
so that, when we stand or sit, the base, fixed by the attachments of the 
large vessels, is directed upwards, backwards, and to the right ; the 
apex downwards, forwards, and to the left ; the base separated from 
the fifth, sixth, and seventh dorsal vertebrae by the descending aorta 
and oesophagus ; the apex, when the ventricles are contracted, and the 
respiration tranquil, corresponding to the space between the fifth and 
sixth ribs — a point about two inches below, and one inch to the inside 
of the left nipple, or two inches and a half from the left border of the 
base of the ensiform cartilage. One half the heart, consisting of a small 
part of the left auricle and the whole of the left ventricle, and the left 
vertical half of the right ventricle, lies to the left of the sternum, behind 
the cartilages of the fourth and fifth, and the sternal articulations of 
the fifth, sixth, and seventh ribs, and the fourth, fifth, and sixth inter- 
costal spaces : the other half of the organ, consisting of nearly all the 
rest of the right ventricle, lies behind the lower halt of the sternum, a 
small part only of the ventricle and the right auricle being behind the 
sternal articulations of the third, fourth, and fifth ribs, and the fourth 
and fifth right intercostal spaces. The flat under and posterior surface 
of the left ventricle lies upon the diaphragm, which separates it from 
the left lobe of the liver; the rounded right ventricle is turned upwards 
and forwards, separated from the sternum and thin anterior edges of the 
lungs by the pericardium and loose cellular membrane connected with it. 



164 SYMPTOMS AND SIGNS OF DISEASE. 

722. The orifices and valves, which are the seat of the sounds heard 
on applying the ear or the stethoscope over the heart, are very close to 
each other, the orifice of the aorta (L, Fig. 44) lying directly behind that 
of the pulmonary artery (2), while the right and left auriculo- ventri- 
cular orifices (3 and 4) are only a third of an inch apart, and just below 
those of the arteries. The diagram (Fig. 44) shows, in horizontal sec- 
tion, both the relative positions of the valves and the relative thickness 
of the walls of the right ventricle (5) and left ventricle (6). 

Fig. 44. 



^0SB^- 




723. The position of these valves in the healthy subject, relatively to 
the bones and walls of the chest, has been determined by transfixing them 
with needles. It has been thus ascertained that, in the recumbent pos- 
ture, the bulging part of the pulmonary artery corresponds to the space 
between the second and third ribs of the left side, close to the sternum ; 
so that a line, 6 6, Fig. 45, drawn across the sternum to the lower mar- 
gin of the third ribs, passes over the valves of the pulmonary artery, a 
little to the left of the mesial line (at v), and about half an inch above 
the valves of the aorta, which lie (in the erect position of the body) behind 
the pulmonic valves. The auriculo- ventricular orifices are, in like manner, 
found to correspond to a line drawn across the sternum at a somewhat 
lower level in the interspace of the third and fourth ribs, the valves 
themselves being situate somewhat to the right and left of those of the 
aorta and pulmonary artery respectively. 

724. As a knowledge of the exact relation of the heart, and of its 
several parts, to the bones and walls of the chest is very conducive to a 
sound diagnosis of its diseases, the facts already stated will be briefly 
recapitulated, reference being made to the annexed engraving. 

725. 1. Parts of the Heart and Large Vessels not covered by the 



POSITION OF THE HEAKT AND LARGE VESSELS. 



165 



Lungs, and separated from the walls of the Chest only by the Pericar- 
dium and loose Cellular Tissue. — The root of the pulmonary artery ; the 
ascending aorta ; the anterior surface of the right ventricle ; a small por- 
tion of the appendix of the right auricle, with the apex and anterior 
margin of the left ventricle, tee 1 and 2, Fig. 40, and the unshaded 
portion of the heait in Fig. 45. 




2. Pulmonary Artery. — Close to the sternum, in the interspace of the 
second and third ribs of the left side. 

3. Aorta, — The ascending aorta lies behind the mesian line of the 
sternum ; it makes its first bend behind the manubrium, and is then 
directed obliquely backwards and to the left, forming the arch, the crown 
of which is on a level with the first intercostal space. The descending 
aorta commences on the left of the third dorsal vertebra. 

4. Valves of the Pulmonary Artery and Aorta. — The first of these 
is situate immediately to the left of the intersection of a line, b b, drawn 
across the sternum to the inferior margins of the third ribs, with the 
mesial line, a a. The latter lie immediately behind those of the pulmo- 
nary artery on a level with the body of the fifth dorsal vertebra. 

5. Auriculo- Ventricular Valves. — To the right and left of the valves 



166 SYMPTOMS AND SIGNS OF DISEASE. 

of the aorta and pulmonary artery respectively, about a third of an inch 
apart, the tricuspid being somewhat lower than the mitral. 

6. Apex of the Heart. — When the body is erect and the breathing 
tranquil, this is felt beating between the fifth and sixth ribs of the left 
side, an inch and a half below, and an inch to the inside of the left nipple. 

726. In examining the heart, three points demand attention — imposi- 
tion and size, its motions, its sounds, 

727. Position and. Size of the Heart. — These are determined chiefly by 
percussion, and, in some cases, though with less accuracy, by the touch. 
In healthy and well-formed persons a dull sound is elicited by percussion 
over an area of about two inches in diameter, extending from the point 
where the heart's beat is felt to the left side of the lower half of the 
sternum. This space, which corresponds to the part of the heart un- 
covered by the lungs, yields a dull sound, both on strong and slight per- 
cussion. Beyond this space the sound is gradually softened off, in pro- 
portion as the thickness of the overlapping lung increases ; but on strong 
and sharp percussion, the dull sound is heard through the intervening 
portion of lung. When the heart is enlarged, or the pericardium filled 
with fluid, the region of dulness is increased. The same effect is pro- 
duced by consolidation of the surrounding lung, by tumours between the 
pericardium and walls of the chest, by partial pleuritic effusions confined 
by false membranes, or even by enlargement of the left lobe of the liver. 
It is only in the ascertained absence of such diseased conditions that the 
extent of dulness on percussion may be taken as the measure of the heart's 
size. (See Figs. 38 and 39, in which the area of dulness in health and 
its extension in disease are compared.) 

728. On the other hand, the absence of dulness on percussion does not 
afford certain evidence of non-enlargement of the heart ; for emphysema 
of the lung, pneumothorax, or even distension of the stomach with gas, 
may give rise to so clear a sound on percussion as to mask the heart- 
affection. The dulness also ceases, even in healthy persons, on lying 
down, or taking a deep breath. The persistence of a dull sound under 
these circumstances affords evidence either of adhesions of the heart or 
lungs, or of such an enlargement of the heart, or distension of the peri- 
cardium, as prevents the heart from receding. 

729. Motions of the Heart. — The auricles and ventricles contract 
alternately, the systole of the one being synchronous with the diastole of 
the other. The auricles first contract, then the ventricles. The con- 
traction of the ventricles is followed by their diastole, and this by a short 
pause. During the diastole of the ventricles, and the short pause that 
succeeds, the blood flows from the auricles into the ventricles, and the 
contraction of the auricular appendices which immediately succeeds the 
pause excites the ventricles to new contraction. The order, therefore (or 
rhythm), of the heart's movements is as ibllows : — systole of ventricles, 
diastole of ventricles, systole of auricles, pause. Of the whole time con- 
sumed, the systole of the auricles and the systole of the ventricles occupies 
one-half, the diastole of the ventricles a fourth, and the pause a fourth. 



IMPULSE AND SOUNDS OF THE HEAKT. 167 

730. The impulse of the heart is synchronous with the contraction of 
the ventricles and the pulse in the large arteries. It was formerly attri- 
buted to the tilting of the apex against the ribs, but it is now understood to 
depend on the sudden change of shape and rigid contraction which the heart 
undergoes — the anterior surface bulging through its entire length. The 
effect of this sudden bulging of the rigid w T alls of the ventricles is felt 
chiefly at the apex ; for a thick mass of spongy lung absorbs and neutral- 
ises the force of the impulse over the rest of the heart's surface. A full 
expiration, by lessening the intervening portion of lung, extends the limits 
of the impulse ; and the same result follows when the body is bent forward. 

731 . The strength of the impulse, and the extent of surface over which 
it is felt, vary greatly in disease. When the w T alls of the heart are thickened 
at the expense of its cavities (concentric hypertrophy), the impulse is little 
increased in extent, but greatly augmented in force; but when the walls 
are thin and the cavities large, the impulse is of less force, but greater 
extent. If thickening of the walls is accompanied by increased size of 
the cavities (in which case the heart w T ill be greatly enlarged), the im- 
pulse is both stronger and more extensive, and may be felt over a space 
of five or six square inches. 

732. Fluid in the pericardium renders the impulse indistinct, and its 
place variable. Adhesions of the heart and pericardium, on the con- 
trary, confine the impulse to the same spot, so that change of posture, 
and the different states of the walls of the chest in inspiration and ex- 
piration, have little or no effect upon it. Tumours within the chest 
and diseases of the lungs may displace the heart, and shift the spot in 
which its impulse is felt. Congenital transposition of the heart has the 
same effect. The impulse will be more distinctly felt, ceteris paribus, 
when the contraction of the ventricle is abrupt. 

733. When the heart beats strongly, and especially in emaciated sub- 
jects, its movements may be seen as well as felt, and their force, extent, 
and nature furnish useful indications. When the heart is enlarged, 
these movements are perceptible in the epigastric region. 

734. The heart is also subject to irregularities of action ; such as 
double and triple impulse, depending generally on spasmodic and partial 
contraction of the ventricles, and on irregular transmission of blood from 
the auricles ; to intermittence, inequality, and increased or diminished 
force. As these produce appreciable changes in the pulse, they w T ill be 
considered under that head. 

735. Sounds of the Heart. — The natural sounds of the heart are two 
— -a dull, prolonged sound, synchronous with the contraction of the 
ventricles, the heart's impulse, and the pulse in the larger arteries ; and 
an abrupt, clear sound immediately succeeding the first, and followed 
by a silent interval. The first sound is loudest over the middle of the 
ventricles, the last over the site of the semilunar valves, and for a short 
distance upwards along the sternum. They are most distinct when the 
pulse is slow, and are mora clear in thin than in stout persons. We 



168 SYMPTOMS AND SIGNS OF DISEASE. 

may hear them in our own persons when lying on the left side ; and 
in disease they may sometimes be heard at a short distance from the 
patient. The intensity of the sound diminishes as the distance from the 
praecordia increases. 

736. In stout persons, the sounds are limited to the region of the 
heart itself; in narrow-chested persons, and in children, they may be 
heard all over the chest, before as well as behind. Any cause which 
increases the conducting power of the contents of the chest, such as con- 
solidation of the lungs in pneumonia and phthisis, extends the limits 
within which the sounds are audible. When consolidation is confined 
to the right side, the sounds of the heart are heard more distinctly on 
that side, both before and behind, than on the left. 

737. Cause of the Sounds. — The dull, heavy, prolonged first sound 
is caused by the contraction of the ventricles and their musculi papil- 
lares. sti etching the cordse tendineae and the membranous valves (tri- 
cuspid and bicuspid) into which they are inserted. The second sound 
is owing to the sudden expansion and flapping together of the semi- 
lunar valves. 

738. The sounds of the heart may be changed in intensity or in 
kind. An increased loudness of sound is often heard during nervous 
palpitations, bo f h by the patient himself and by his attendants ; it may 
also be produced by dilatation of the ventricles, with thinness of their 
parietes. In the former case, the impulse is increased ; in the latter, 
diminished. On the other hand, the sounds may be so feeble as to be 
heard with difficulty ; as happens in general debility, in obstructed pul- 
monary circulation, when the heart is overloaded with blood, in soften- 
ing of its fibres, and in excessive hypertrophy. In the latter case, there 
will be strong impulse with weak sounds. 

739. In cases of nervous palpitation, and after strong exercise, both 
sounds of the heart are unusually distinct ; the action of the fibres being 
strong and abrupt, and the valves of the aorta closing with a sudden 
jerk : hence the loudness of the first sound and the abruptness of the 
second. 

740. Of the sounds present in unusual or diseased conditions of the 
circulation some belong to the heart, others to the blood-vessels. They 
are the following : — The bellows sound (bruit de soufflet), the simple 
blowing sound, the hissing sound, the sawing sound (bruit de scie), the 
rasping sound (bruit de rape), a humming sound (bruit de diable), a 
buzzing sound (bruit de mouche), a whizzing sound, and peculiar 
musical sounds, such as cooing, whistling, &c. 

741. The sounds heard over the region of the heart, or in the large 
vessels that spring from it, are chiefly the bellow r s sound and its modifi- 
cations — the sawing or rasping sound, and the musical sounds. 

742. The bellows sound is always produced when there is a marked 
disproportion between the force of the heart's contractions and the size 



ABNORMAL SOUNDS OF THE HEART. 169 

of the tubes or orifices through which the blood has to pass. It may 
arise — 1. In healthy persons, during very strong contraction of the heart, 
the arteries retaining their normal size; in nervous persons, during 
violent palpitations, the heart contracting both quickly and forcibly ; 
in chlorotic females, from, as is thought, a thin condition of the blood ; 
and in cases of great debility from sudden haemorrhage. In these cases 
the sound is not constant. When present, it bears a close resemblance 
to the panting noise of a locomotive starting on its journey. 2. From 
narrowing of the orifices, the heart contracting as usual or with increased 
force : as when the orifice of the aorta or pulmonary artery is contracted, 
with or without enlargement and hypertrophy of the corresponding 
ventricle. 3. From narrowing of the orifices by vegetations, incrus- 
tations, or polypous concretions of the valves. 4. From adhesion of 
the aortic or auriculo-ventricular valves to the adjacent walls. 

743. The young stethoscopist must be guarded against confounding 
a rapid tubular respiration with a bruit de soufflet. When the true caus- 
of the sound is doubtful, the patient must be made to hold his breath. 

The place in which abnormal sounds are heard, and the sound of the 
heart which they accompany, often enable us to fix on their precise seat 
and cause. Thus, sounds heard only in the region of the heart or over 
the valves, and becoming indistinct when the ear follows the course of 
the aorta, but increasing in distinctness as the ear approaches the apex 
of the heart, may be ascribed to disease of the auriculo-ventricular 
valves ; or to causes external to the heart itself, and having the peri- 
cardium for their seat. On the other hand, sounds heard in the site of 
the valves, and remaining equally distinct or increasing in distinctness, 
as the ear follows the course of the large vessels, may be referred to 
diseases of the coats or valves of the aorta or pulmonary artery. Of 
the two auriculo-ventricular valves, the mitral is the most likely seat 
of disease. Of the two arteries and their valves, the coats and valves 
of the aorta are the most liable to structural disease. 

744. If the abnormal sounds accompany the first beat of the heart, 
they are probably due to disease of the auriculo-ventricular orifices, or 
of the valves or coats of the arteries. When they accompany the second 
sound, they probably arise from disease of the aortic valves. Double 
sounds may be due to disease of the auriculo-ventricular valves coincid- 
ing with disease of the valves of the aorta or pulmonary artery ; or to 
disease of the coats and valves of the aorta. 

745. A more exact diagnosis of the causes of abnormal valvular 
sounds may be arrived at by considering together the position of the 
valves and the direction in which the sounds are most readily conducted. 
In the case of the tricuspid the valvular sound conducted by the walls 
of the right ventricle would be most distinctly perceived on the right 
side, and towards the base of the heart ; while abnormal sounds due to 
disease of the mitral valve would be most distinctly heard on the left 
side, and towards the apex. So also with abnormal sounds due to 
disease of the two great arteries. As their coats will be the best con- 
ductors of the sounds produced at the roots of the arteries themselves, 



170 SYMPTOMS AXD SIGNS OF DISEASE. 

or in any part of their course, the sounds will continue distinctly audi- 
ble along the track of the respective vessels, but become less and less 
distinct as the ear travels in a direction from the base to the apex of 
the heart. Aortic murmurs, therefore, will continue distinct behind 
the middle of the sternum, and in the direction of the right sub-clavi- 
cular space ; while pulmonic murmurs, becoming!: indistinct in that 
direction, will be best heard at the left of the sternum, between the 
second and third ribs, and will continue distinct in the track of the left 
pulmonary artery, or for a short distance in the direction of the left 
sub-clavicular space. 

746. The following diagnosis of valvular sounds is in accordance 
with these statements. 

1. A murmur with the first sound of the heart heard over the site 
of the semilunar valves, and distinct at c (Fig. 45, p. 165), is aortic. 

2. A murmur with the first sound heard in the same situation, but 
distinct at d, is pulmonic. 

3. A prolonged murmur with the second sound, loudest over the 
semilunar valves, is due to regurgitation through those valves, — of the 
aorta, if the sound is loudest in the direction c e ; of the pulmonary 
artery, if loudest in the direction d f ; but in either case becoming less 
intense, as the ear travels towards the apex of the heart. 

4. A murmur with the first sound, loudest at /, is from tricuspid 
regurgitation. 

5. A murmur with the first sound, loudest at e, is from mitral re- 
gurgitation. 

6. A murmur with the second sound, loudest at e, is from contrac- 
tion of the mitral; if loudest at/, from contraction of the tricuspid. 

Lastly, as a general rule, a murmur with either sound distinct at c 
and d is semilunar ; if distinct at e and /, it is auricular. 

747. The indication afforded by abnormal sounds over the heart and 
large vessels may often be confirmed or corrected by placing the hand 
on the w r rist, while the ear is applied to the seat of the sounds. In the 
case of abnormal sounds attributed to disease of the auriculo-ventri- 
cular valves, if the sound precede the pulse, we may attribute it to the 
entry of the blood into the ventricle : if it be synchronous w T ith it, to 
reflux. In this latter case, the presence of the venous pulse, that is to 
say, the pulsation of the large veins on the right side of the neck caused 
by regurgitation into them, indicates that the right side of the heart is 
affected. These indications may also be confirmed or corrected by 
attending to such leading symptoms as the pulse and respiration, and 
the presence of haemorrhages and dropsical effusions. For instance, an 
irregular, uneqnal, and feeble pulse is common in disease of the mitral 
valve, but a full, hard, regular, thrilling pulse in disease of the aorta. 
Dropsies are more common in disease of the right side of the heart, 
affections of the lungs in disease of the left side, and head symptoms in 
disease of the aorta. 

748. The sounds heard in the region of the heart, from causes external 



THE PULSE. 171 

to it, are superficial friction sounds, generally double, and in rare cases 
triple or fourfold. They arise fiom deposits of coagulable lymph on the 
pericardium, or from other morbid formations in the same situation. 
They are of limited extent, and are not heard in the course of the large 
vessels. They resemble those produced by depositions of lymph on the 
pleura, and vary in intensity, fioni a sound closely allied to the bruit de 
soufflei, to the harsh sound produced by sawing wood. 

749. The hand applied to the spot where an abnormal sound is heard 
perceives a peculiar thrilling vibratory motion, like that felt on touching 
the back of a cat in the act of purring. This is called the purring tremor 
(fremissement cataire). A similar thrill is sometimes felt under strong 
pressure in the healthy arteries themselves, after profuse loss of blood, 
and in anaemia. It is also present over aneurismal tumours, in aortic 
dilatations, in arterial varix, and in regurgitant valvular disease. 

750. The most common sound in the vessels remote from the heart is 
the bellows murmur. This may always be produced, both in arteries and 
veins, by the firm pressure of the stethoscope, but is most distinctly heard 
in chlorotic females, and after haemorrhages. It is heard in the veins of 
the uterus during pregnancy, but may be produced by pressure of the 
stethoscope transmitted to the iliac veins, or aorta. 

751. The humming sound (bruit de diable) and the buzzing sound 
{bruit de mouche) are also heard in different states of the vessels, and in 
the large veins under the pressure of the stethoscope. They may be 
heard in most anaemic females by placing the stethoscope with a rirm 
pressure in the supra-clavicular space; but they are not peculiar to 
anaemia. They are generally most distinct on the left side, but, in rare 
instances, are perceptible only on the right side or only on the left. 

752. This humming or buzzing sound is distinguished from sounds 
due to the motion of the blood in the arteries by being continuous. Some- 
times, as in extreme cases of anaemia, a humming sound, due to the 
motion of the blood through the veins, is heard at the same time with a 
bellows sound caused by the motion of the blood through the arteries. 
This combination is best heard above the clavicles. 

753. The peculiar whizzing or grating sound of aneurism, and of 
aneurismal varix (an accidental opening from an artery into a vein), 
completes the history of valvular sounds. 

4. The Pulse. 

754. By the ear or hand applied to the region of the heart, we count 
the number, force, quickness, regularity, and degree of equality of its 
beats ; but the pulse teaches us this and something more. Jt is a mea- 
sure not only of the number, force, quickness, regularity, and degree of 
equality of the heart's contractions, but also of the quantity of blood sent 
forth at each beat. Hence it is a better measure of the circulation. It 
would be a perfect one were it not that the coats of the arteries vary in 
their contractility. But this circumstance gives the pulse an additional 



172 SYMPTOMS AXD SIGNS OF DISEASE. 

claim to attention ; for it serves as an index of the state of the nervous 
system ; by which the contractility of the arteries is determined. 

755. The fallaciousness of the pulse has passed into a proverb, and the 
proverb has furnished a good excuse for neglect. Substitute the word 
" difficult " for the word "fallacious," and we have a motive for indus- 
try instead of an apology for idleness. The pulse can only be fallacious 
to the extent to which we are ignorant of it ; it will always remain dif- 
ficult even to those who understand it best. The difficulties that attach 
to the subject are the same which beset every part of the study and prac- 
tice of medicine, and they spring from the same causes — of which the 
chief are the original difference in degree existing between all the func- 
tions of the healthy body, the variable intensity of the causes of disease, 
and the many combinations of which those causes are susceptible. 

756. Some precautions are necessary in examining the pulse and some 
directions are required. The first precaution to be observed is, to wait 
a certain time till the emotions commonly occasionel by the presence of 
the medical attendant have subsided, for such emotions have a marked 
effect on the circulation. For the purpose of counting the number of 
beats, a single ringer may be used; but in order to observe the more mi- 
nute changes of the pulse, the four fingers of the ojyposite hand should 
be applied in the course of the radial artery, with a moderately firm and 
equal pressure. By compressing the artery with the ring or little finger, 
we can ascertain by the forefinger the degree of compressibility. In in- 
fants and very young children, it is often difficult to count the pulse at 
the wrist, and in these cases the beat of the heart should be preferred. 
The pulse of infants should, if possible, be counted while they are asleep. 

757. Of all the characters of the pulse, its frequency is the one most 
easily ascertained. This usually corresponds with the number of the 
heart's contractions : it can never exceed that number, though it may 
fall short of it. Tn certain forms of heart disease, the ventricles receive 
so small a quantity of blood that no impression is made on the mass of 
the circulating fluid, and the impulse does not reach the radial artery : 
or the heart, contracts without having any blood in it; or some pressure, 
temporary or permanent, exists in the course of the artery : in all these 
cases, the pulse is imperceptible, and we miss some of its beats. In syn- 
cope, all the beats of the heart are so feeble that no pulse can be felt at 
the wrist. 

758. The number of the pulse in health varies with age, sex, and tem- 
perament ; with posture, time of day, sleep, exercise, food ; with mental 
emotions ; with temperature and density of the air ; with the quantity 
of blood in the body ; and with the strength and vigour. Our principal 
information on this subject is condensed in the following pages : — 

759. Age. — Infancy. — The number of the pulse is very variable in 
infants. In the healthy infant asleep on the day of its birth, Heberden 
found it to be between 130 and 140 ; and, according to Quetelet, the num- 
bers immediately after birth, both for males and females, are as follow : — 

Maximum, 165 ; Minimum, 104 ; Mean, 135 ; Range, 61. 



THE PULSE AT DIFFERENT AGES. 173 

The following numbers are from Billard ; the averages are approxi- 
mations : — 

Max. Min. Mean. Range. 

1 to 10 days 180 : less than 80 (in 18) 106 ; more than 100 

1 to 2 months 150; .... 70 ... 103; 80 

1 to 3 months 100; .... 70 . . . 87; 30 

The pulse of the infant at birth, and for some time after, is. therefore, 
very variable, and is little to be depended on as an indication of health. 

760. From infancy till towards the middle of life, the number of the 
pulse progressively diminishes, to increase again slightly in the decline of 
life. The following table, founded on an aggregate of about 700 obser- 
vations, of which the greater number were made by myself, shows, for 
the first 25 years of life, the average and extreme numbers of the pulse, 
without distinction of sex, time of day, or posture of the body. The 
table shows an uninterrupted fall from 128 to 90, in the first seven years 
of life, and a further fall (with irregularities due to the small number of 
observations) during the 18 years which follow : also a range, for the 
whole period of 25 years, varying from 56 to 29, and displaying a pro- 
gressive decrease with fluctuations dependent on the same cause. 



Age. 


Max. 


Min. 


Mean. 


Range. 


1 


158 


108 


128 


50 


2 


136 


84 


107 


52 


3 


124 


84 


106 


40 


4 


124 


80 


105 


44 


5 


133 


80 


101 


53 


6 


124 


70 


95 


54 


7 


128 


72 


90 


56 


8 


112 


72 


92 


40 


9 


114 


65 


87 


49 


10 


120 


76 


91 


44 


11 


100 


56 


84 


44 


12 


120 


70 


94 


50 


13 


112 


70 


84 


42 


14 


114 


68 


86 


46 


15 


112 


60 


84 


52 


16 


104 


66 


83 


38 


17 


102 


54 


76 ' 


48 


18 


104 


58 


74 


46 


19 


108 


60 


76 


48 


20 


106 


52 


72 


54 


21 


99 


59 


74 


40 


22 


96 


41 


68 


55 


23 


100 


60 


74 


40 


24 


84 


52 


71 


32 


25 


88 


59 


73 


29 



761. The following table shows the number of the pulse at different 
ages, based on twenty-five observations at each age, all of which obser- 



174 



SYMPTOMS AXD SIGNS OF DISEASE. 



rations were made in apparently healthy persons, fasting, at rest, in the 
middle of the day, and in a sitting posture: — 







Ma 


LES. 






Females. 




Age. 




















Max. 


Min. 


Mean. 


Range. 


Max. 


Min. 


Mean. 


Range. 


1 week, 


160 


104 


128 


56 


160 


104 


128 


56 


2 to 7 vears 


128 


72 


97 


56 


128 


70 


98 


58 


7—14 


108 


70 


84 


38 


120 


70 


94 


50 


14—21 


108 


60 


76 


48 


124 


56 


82 


68 


21—28 


100 


53 


73 


47 


114 


54 


80 


60 


28—35 


92 


56 


70 


36 


94 


62 


78 


32 


35—42 


90 


48 


68 


42 


100 


56 


78 


44 


42—49 


96 


50 


70 


46 


106 


64 


77 


42 


49—56 


92 


46 


67 


46 


96 


64 


76 


32 


56—63 


84 


56 


68 


28 


108 


60 


77 


48 


63—70 


96 


54' 


70 


42 


100 


52 


78 


48 


70—77 


94 


54 


67 


40 


104 


54 


81 


50 


77—84 


97 


50 


71 


47 


105 


64 


82 


41 



762. The pulse of the adult male, then, may be stated at 70, that of 
the adult female at 80 ; the highest number is somewhat less than 100 
in the male, and somewhat more than 110 in the female ; the least num- 
ber in each is about 50. The range (difference between the highest and 
lowest numbers) extends from 28 to 56 in the male, ayerage 43 ; and 
from 32 to 68 in the female, average 48. The lowest number in the 
table is 46 ; the lowest observed by Floyer, was 55. 

763. Much lower numbers have, however, been met with in healthy 
persons. Heberden records, 42, 30, and even 26 beats in a man whose 
" chief distemper " was the age of fourscore ; and Fordyce, 26, in an old 
man in the Charter-house. In a young man whose pulse is not included 
in the table (he then suffered from slight dyspepsia, and has since died 
of consumption), I have repeatedly counted as low as 38 beats ; and in 
a medical man who had been reduced to extreme weakness by a succes- 
sion of exhausting maladies, and slowly recovered health and strength, 
1 have counted as few as 30 beats ; which, or a near approach to it, con- 
tinues to be the usual number at an interval of some years from the 
date of his recovery. Pulses as low as 16 or even 14 are on record, but 
it is doubtful whether the persons in whom they occurred were healthy. 
Falconer has observed pulses of 36 and 24 in women, and Dr. Graves 
one of 38. 

764. In disease, extraordinarily small numbers have been counted ; 
one case is reported by M. Piorry, in which there were 17 beats in a 
minute ; in a case of epilepsy (Sir W. Burnett) the number was 14 ; 
Heberden was told of a pulse of 12 or 16 ; and in a remarkable case of 



THE PULSE IX THE TWO SEXES. 175 

injury to the upper part of the spine, followed after an interval by fits 
of syncope with convulsions, the pulse was usually about 33, but fell 
during the fits to 12, 10, 8, " and at three or four different times, when 
the patient was quite insensible, and not in a fit," 7£ in a minute. 
(Mr. Holberton, in Med.-Chir. Trans. 1841.) These low frequencies of 
pulse are generally little affected by stimuli, and, as in the case reported 
by Dr. Graves, remain unaltered by febrile attacks. 

The pulse often falls very low during convalescence from fevers and 
other exhausting maladies ; and a very infrequent pulse has been speci- 
ally noted among the anomalous symptoms of diphtheria. 

765. It is probable, on the other hand, that there are exceptions of 
an opposite kind — that is, cases of great frequency of pulse ; but I have 
not met with any well-authenticated instances. In disease, very high 
numbers have been encountered. Dr. Joy counted 200 in a case of 
acute hydrocephalus, and I was informed by a medical man, that during 
occasional violent fits of palpitation he counted in his own person 250 
beats in the minute, and that a medical friend corroborated his state- 
ment as to the number. Heberden met with a pulse of 180, though 
Floyer thought that the greatest number which could be counted was 
140, I have myself counted upwards of 170 in pulmonary consump- 
tion ; and during the rapid formation of diffused abscess of the arm, in 
a boy ten years of age suffering from a fatal attack of typhoid fever, I 
distinctly counted 264 beats in the minute, being nearly nine in two 
seconds. 

766. Sex. — On comparing the two columns of the last table, it will 
be seen that the pulse of the female has nearly the same number as that 
of the male up to seven years, but that at more advanced periods of life 
the female pulse is in excess by from 6 to 14 beats, the average excess 
being 9. The pulse, too, has a greater range in the female ; that is to 
say, there is a greater difference between its highest and lowest num- 
bers ; the female pulse being often much more frequent than the male, 
while in other instances it falls nearly as low. 

767. As it is not easy to bear in mind the number of the pulse in the 
two sexes for the several periods specified in the tables, the following 
approximate figures may assist the memory : — 



1. At birth 

2. Infancy 

3. Childhood . 

4. Youth 

5. Adult Age . 

6. Old Age . 

7. Decrepitude . 



140 

120 

100 
90 
75 
70 
75- 



An addition of about 10 beats will have to be made to 4, 5, and 6, in 
order to give the numbers in the female. 

768. Temperament. — Nothing is certainly known of the influence of 



176 



SYMPTOMS AND SIGNS OF DISEASE. 



temperament on the pulse. It is probably more frequent in the sanguine 
and nervous than in the lymphatic and bilious ; but I have counted a 
pulse of 50 in a youth under 20 years of age, with every mark of the 
sanguine temperament. 

769. Posture. — In the healthy adult male the mean frequency of the 
pulse in the different postures is as follows : — 

Standing, 79 ; sitting, 70 ; lying, 67 ; including all exceptions to the 
rule. 

Standing, 81 ; sitting, 71 ; lying, 60 ; excluding all exceptions. 
In the adult female of the same mean age the numbers are — 
Standing, 89 ; sitting, 82 ; lying, 80 ; including all exceptions. 
Standing, 91 ; sitting, 84; lying, 80 ; excluding all exceptions. 

770. The extremes are very remote from these mean numbers. 
Thus, in men, the difference between standing and sitting has been ob- 
served as high as 26, and as low as ; that between sitting and lying 
as high as 18, and as lew as ; and that between standing and lying as 
high as 4-1, and as low as 0. In women, differences scarcely less marked 
have been observed. Numerous exceptions also exist to the rule that 
the pulse is more frequent sitting than lying, and standing than sitting. 
The effect of change of posture on the same number of the pulse is 
nearly twice as great in males as in females, and nearly three times as 
great in adults as in early youth. 

771. The effect of change of posture increases with the frequency of 
the pulse, as is seen in the following tables : — 



Standing 

Sitting .... 

Lying .... 

Difference between] 
standing and lying J 



51-70 



61 



71-90 



81 
68 
67 



14 



91-110 111-130J 



101 
82 
74 



27 



120 
93 
81 



39 



Standing 
Sitting . 
Lying . . , 

Difference between) 
standing and lying) 



81-100 101-120 



71 


92 


108 


67 


85 


97 , 


63 


83 


90 



18 



THE PULSE AS AFFECTED BY VARIOUS CAUSES. 177 

772. The exceptions to the general rule decrease as the frequency of 
the pulse increases, and for the higher numbers entirely disappear. The 
effect of change of posture on the same number is greater in the morning 
than in the evening. When the head is placed lower than the body the 
pulse falls. 

773. The number of the pulse in the different postures is determined 
by the muscular effort required to support the body in those postures. 

774. The effect of change of position is much increased by debility, 
but diminished in phthisis pulmonalis, and, according to Dr. Graves, is 
reduced to zero in hypertrophy of the heart. 

775. Period of the Day. — The pulse of the healthy male is, as a 
general rule, more frequent morning than evening, and diminishes pro- 
gressively as the day advances. To this rule there are many exceptions in 
men, and still more in women. The fall is also more rapid and uniform in 
the evening than in the morning. It is also a general rule that all ex- 
citing causes act more powerfully on the pulse in the morning than in 
the evening. 

776. In experiments on the pulse in my own person, I found that the 
effect of the same food on the same number of the pulse was, taking one 
experiment with another, nearly twice as great, and lasted more than three 
times as long, in the morning ; while in more than one instance the same 
food which in the morning raised the pulse from 5 to 12 beats, and kept 
it raised for one or two hours, had no effect whatever in the evening. 

777. Sleep. — The pulse falls considerably in sleep. Qnetelet found 
a difference of 10 beats in an adult female, the same difference in a girl 
from three to four years old, and in a boy from four to five years a dif- 
ference of 16 beats. Sleeplessness excites the circulation. 

778. Exercise. — This excites the pulse more than any other cause. 
It may raise it to more than three times its natural number. Change 
of posture is but a particular case of this. After severe and continued 
exertion, as I have shown experimentally, the pulse suffers the same 
collapse as the other functions, and falls much below its natural number. 
Passive exercise also excites the pulse. 

779. Food. — The pulse is little affected by vegetable food, more by 
animal substances, most of all by warm drinks. Spirituous liquors and 
tobacco, even though used habitually, raise it ; cold liquids lower it. 

780. Mental Emotions. — These have a marked effect on the pulse, the 
exciting passions raising it, the depressing passions lowering it. The ap- 
prehension which patients feel in the presence of their physician is well 
known to excite the pulse, and the caution not to count it till the ex- 
citement has ceased is as old as Celsus. 

781. Temperature of the Air. — Cold air lowers the pulse, warm air 
raises it. When Sir C. Blagclen remained eight minutes in air heated 
to 260°, the pulse rose to 144, double its natural number. 



178 SYMPTOMS AUD SIGKS OF DISEASE. 

782. Density of the Air. — On the summit of Mont Blanc, De Saus- 
sure iound the pulses that beat 49, 66, and 72 times respectively at 
Chamounix, raised to 98, 112, and 100. 

783. Quantity of Blood in the Body. — The pulse is more frequent in 
that degree of plethora which falls short of overloading the heart with 
blood ; its frequency is hut little increased when the heart is oppressed. 
Compression of the arteries raises the pulse by producing the first degree 
of plethora. A slight decrease in the quantity of blood lowers the pulse; 
a considerable decrease raises it. 

784. Debility — In debility without disease the pulse falls : it rises in 
extreme weakness, or when debility is complicated with irritation. 

785. The common causes of increased frequency of pulse in healthy 
persons, therefore, are the following : Muscular exertion, active and pas- 
sive exercise, a change from a posture requiring less effort to one lequiring 
more, food (especially warm drinks, spirituous liquors, and tobacco), 
heat, diminished pressure of air, extreme debility, sleeplessness, the first 
degree of plethora, and exciting passions and emotions. 

786. The chief causes of diminished frequency, on the other hand, 
are, sleep, fatigue (provided it be not carried to excess), change of pos- 
tiue from one requiring greater effort to one requiring less, the inverted 
position of the body, continued rest, debility without disease (provided 
it be not extreme), cold applied externally or taken internally, increased 
atmospheric pressure, and depressing passions. 

787. Other characters of the pulse, besides its frequency, deserve 
notice. The pulse of healthy men may be described as regular, mode- 
rately full, compressible, and rising slowly under the finger ; that of 
healthy women and children as smaller and quicker in the beat. The 
pulse in the sanguine temperament is full, hard, and quick; in the 
lymphatic temperament, slower in the beat. In old age the pulse is 
often rendered hard by the increased firmness of the arteries. 

788. Exceptions also occur as to the regularity of the pulse, instances 
having been observed in which the pulse was irregular or even inter- 
mittent in health, and regular in disease, resuming its intermittent cha- 
racter on recovery. Heberden records two cases in which the pulse 
that was both irregular and unequal in health, became regular during 
illness. In some persons this irregularity occurs on every slight attack 
of indigestion, especially where much flatulence is present. 

789. The number of the pulse, then, though a point of much import- 
ance, is not the only one that demands attention : it has other charac- 
ters of at least equal value. The following description and explanation 
of them will be tound useful. 

790. The impression made on the finger by the pulse is compounded 
(a) of the beat of the heart, (6) of the reaction of the aorta and large 
vessels, ( c) of the condition of the coats of the artery, (d j of the con- 
sistence of the blood, and (<?) of the state of the aortic valves. 



VARIETIES OF THE PULSE AND THEIR CAUSES. 179 

791. (a) The characters of the pulse which depend upon the degree 
and mode of the heart's contraction are the following : — 

Number of the heart's contractions. — Pulse frequent, infrequent. 

Regularity of the heart's contractions. — Pulse regular, irregular 
(intervals unequal), intermittent (intervals equal). 

Quantity of blood expelled by the heart. Pulse large (full), small. 
If the quantity at each beat is the same, the pulse is equal ; if different, 
unequal. 

Time occupied by each beat of the heart. — Pulse slow (labouring] , 
quick (sharp), very quick (jerking or hounding). 

792. (o) The strong and firm reaction of the healthy elastic coal of 
the arteries produces a steady pulse; the absence of this reaction in the 
large arterial trunks occasions the peculiar thrilling pulse of aortic 
disease and of aneurism. The following modifications are due to this 
cause : — 

Elasticity of the arteries increased. — Pulse hard (strong, sharp, 
wiry, incompressible). 

Elasticity of the arteries diminished. — Pulse soft (weak, yielding 
compressible . 

Elasticity lost in the large arterial trunks. — Pulse jerking, thrilling. 
vibrating. 

793. (c) The character of the pulse is further modified by the degree 
of contractility of the muscular fibres which the coats of the smaller 
arteries contain. This condition may be conveniently expressed by the 
word tone. It exists in every degree from the tense state of high ner- 
vous excitement or rude robust health, down to the flabby condition of 
collapse, shock, or extreme debility. 

794. (d) The influence which the consistence of the blood has in 
modifying the pulse is best seen in extreme cases of anaemia, in which 
an important element being deficient, the pulse assumes the thrill that 
in other cases is due to a loss of elasticity in the arteries. 

795. (e) The state of the aortic valves has a marked effect on the 
pulse. In health their prompt closure keeps the arterial system full, 
and conduces to the steady character of the pulse. But when the valves 
are so diseased as to prevent their closure, and allow regurgitation into 
the left ventricle, each pulse is peculiarly distinct, the wave caused by 
the contraction of the ventricle being felt as if the blood were ' shot 
under the finger,' the vessel in the interval being unusually empty. 
This pulse is an exaggeration of the jerking pulse of anaemia. 

796. The foregoing characters of the pulse are rarely, if ever, met 
with separate, but admit of various combinations, of which the following 
are the most important : — 

Pulse frequent, large, soft. — (Compounded of a frequent beat of the 
heart, a large quantity of blood sent out by each contraction, and an 
artery wanting in elasticity and tone.) This pulse accompanies the pre- 
monitorv stas;e of manv febrile and exanthematous diseases, such as scar- 



180 SYMPTOMS AND SIGNS OF DISEASE. 

latina, quinsey, erysipelas, typhus and enteric fever, the first stage of 
pneumonia, &c. It is also present in dilatation of the left ventricle of 
the heart. 

Pulse frequent, large, hard. — (Compounded of a frequent beat of the 
heart, a large quantity of blood sent out at each beat, and an artery full 
of elasticity and tone.) The pulse of the first degree of plethora and of 
hypertrophy with dilatation of the heart. 

Pulse rather frequent, large, slow (labouring). — Compounded of a 
rather frequent and slow beat of the heart, and a large quantity of blood 
seat out at each contraction.) The pulse of a greater degree of plethora, 
the heart overloaded with blood. 

Pulse frequent, large, hard, quick. — ^Compounded of a frequent and 
quick beat, a large circulation of blood, and an artery full of elasticity 
and tone.) The pulse of inflammatory fever. 

Pulse frequent, large, hard, thrilling. — ( Compounded of a frequent 
beat of the heart, a large quantity of blood sent out at each beat, the 
artery at the wrist elastic and full of tone, with a loss of elasticity in 
the larger arterial trunks.) The characteristic pulse of aneurism and 
of dilated aorta, without obstruction to the flow of blood. 

Pulse frequent, small, quick. — Compounded of a frequent beat of the 
heart, a quick contraction, and a small quantity of blood sent out at 
each beat.) This is the characteristic pulse of phthisis in males, and of 
anaemia in females. In a moderate degree, indeed, it is the character 
that marks the female pulse, and is present in an exaggerated form in 
all the less severe disorders of women. With the addition of extreme 
hardness it is the pulse of hypertrophy with contraction of the heart. 

Pulse unequal and irregular, frequent or infrequent. — (Compounded 
of a variable quantity of blood sent out at each contraction, and of con- 
tractions performed in unequal times.) As the quantity of blood sent 
forth by the heart may depend upon one of two causes, — diminished 
supply from the auricle, or want of power in the heart, — this pulse 
may indicate mitral valve disease, or atrophy or softening of the heart. 
It may depend, also, on causes which render the supply of blood to the 
left auricle variable. Hence it occurs in some diseases of the lungs. A 
similar pulse may occur suddenly as the consequence of the formation of 
a large polypus in the left ventricle, or from pressure exercised upon the 
heart by effusion into the pericardium. 

Pulse infrequent, large, hard. — (Compounded of an infrequent beat 
of the heart, a full supply of blood, and an artery in a state of elasticity 
and tone.) A pulse met with in apoplexy before depletion has been 
practised, in hydrocephalus, in compression of the brain, in naicotism, 
and in simple hypertrophy of the left ventricle. 

Pulse infrequent, quick. — ( Compounded of an infrequent and a quick 
beat of the heart.) A pulse sometimes met with in the hysteric female, 
and in very rare cases of phthisis in the male. 

797. These are the leading combinations of the chief elements of the 
pulse. They are given partly as examples of the use of terms, partly 
as hints to those who may wish to follow out the study of the pulse. 



THE PULSE IN DISEASE. 181 

798. Taken in combination with other symptoms, the pulse furnishes 
important indications in all diseases ; while in pulmonary consumption 
and diseases of the heart and arteries, it often gives the earliest clue to 
the existence of an obscure and lurking malady. 

799. It must not, however, be supposed that the pulse is free from 
the uncertainties that attach to all other symptoms of disease. On the 
contrary, we encounter, from time to time, remarkable exceptions to 
general rules. There are no characters of the puis?, for instance, more 
generally present than those just indicated as occurring in pulmonary 
consumption, especially in men ; but among some hundreds of cases 
conforming to the rule of increased frequency, we meet with a single 
case in which the number falls short even of the average in health. In 
one case I counted a pulse of 64 in the erect posture. The dyspeptic 
patient referred to at § 763, as having a pulse of 38, died several years 
afterwards of pulmonary consumption. In other diseases and states of 
system usually characterised bygieat frequency of pulse, curious excep- 
tions do occasionally take place. Thus, there have been epidemics of 
continued fever characterised by a very low frequency ; and cases of all 
the more severe febrile disorders marked by the same curious exceptions 
to the rule. Thus, Dr. Wells counted a pulse of 58 in a boy eight years 
of age, suffering from anasarca after scarlatina. Of the striking differ- 
ence of frequency that may exist in two persons suffering from the same 
disease, Heberden gives a good illustration. Two young women were 
ill of the same infections fever, and the pulse of the one was never 
above 84, while the pul-e of the other was counted as high as 180. Both 
recovered. The low frequency in the first case was thought to be due to 
the state of the brain, u which was affected eomatously." 

800. The pulse in d'sease is also subject to great variations in the 
same persons, either within short intervals of time, or in states of system 
in other respects apparently the same. Thus, it is not uncommon in 
typhus fever to find the pulse varying; in a few hours from 40 or 50 
beats to 120 or 130 ; and in a ease of phthisis, the pulse, which was 64 
in one attack, was 120 in a second, not distinguishable from the first 
by any other symptom. 

Changes in the frequency of the pulse in either direction afford very 
important indications in disease. Thus, Heberden remarks, " that before 
some critical swelling or deposit of matter begins to show itself in fevers, 
the pulse will be so rapid and indistinct as hardly to admit of being 
counted," a statement confirmed by the case cited in § 765. The same 
accurate observer tells us that if, in an illness, a pulse of feverish quick- 
ness all at once becomes quiet, while all the other bad signs are aggra- 
vated, we are to suspect a translation of the diseased condition to the 
brain, and to apprehend apoplexy, palsy, or death: and, again, that if 
the pulse of a child be 15 or 20 below the healthy standard, with signs 
of considerable illness, the brain is certainly affected. 

801. Besides the simple characters of the pulse already described, 
others less common and more obscure have been mentioned by authors, 



182 



SYMPTOMS AND SIGNS OF DISEASE. 



of which the following are examples: — The redoubled pulse (dicrotus, 
bisferiens, bisiliens'), when two strokes follow each other rapidly, and 
are separated from the two succeeding ones by a pause — a pulse said to 
indicate approaching haemorrhage ; the incident pulse (incidens, inci- 
duus), when the second pulsation is weaker than the first, the third than 
the fourth, after which there is a stroke as strong as the first: this is 
the critical pulse of the old writers ; the pulsus caprisans, admirably 
named, but rarely felt ; it consists in a small pulse, succeeded after a 
short interval by a large one, conveying the impression of an unsuccess- 
ful effort, followed by the overcoming of an obstacle. 

Much light has been already thrown on the variations of the pulse 
in health and disease, and more may be confidently expected, by the 
use of the sphygmograph invented by M. Marey, and improved in some 
minor details by Dr. Sanderson. This ingenious instrument may be 
described as a skilful combination of springs and levers, by which all 
the changes that occur in the radial artery in a short period of time can 
be correctly exaggerated and traced on paper, or on an cblong fragment 
of smoked glass. 

It may be well to show by examples the striking differences that 
have been ascertained to exist hetween the pulse in health and in one 
or two diseased conditions. The curves in Fig. 46 show — 1. The 

Fig. 46 



firm long pulse of vigorous health. 2. The soft pulse of ordinary 
health. 3. The hard pulse of chronic Blight's disease. 4. The undu- 
latory pulse of typhus. It will be seen that the number of the pulse 
is indicated as well as its character. Thus, the pulse in 1 is 50 ; in 2, 
56: in 3, 70 ; in 4, 160. These outlines are selected from the plates 
given by Dr. Sanderson in his excellent ' Handbook of the Sphygmo- 
graph,' to which the reader is referred for fuller information. 



THE RESPIRATION AS AFFECTED BY AGE AND SEN. 183 

5. The Respiration. 

802. The number and character of the respiratory movements, and 
the relation they bear to the circulation, frequently engage attention at 
the bedside. In order to appreciate rightly their value as signs of disease. 
it must be borne in mind that the muscles of respiration are under the 
control both of voluntary and involuntary nerves, and that their subor- 
dination to the will renders them liable to all those affections of the 
voluntary muscles in which volition is suspended, lost, or interfered 
with, such as chorea, tetanus, and hysteria. 

803. As respiration may be in part a voluntary net, it is necessary 
in experimental inquiries to eliminate the disturbing element of the will. 
For this purpose, I have devised an instrument which registers the 
number of respirations during a considerable interval without requiring 
the attention of the experimenter. (See § 670.) 

804. At the bedside, the same object may be secured by placing the 
hand of the patient on the abdomen, as if with a view of counting the 
pulse. By relaxing the grasp on the wrist, and allowing the hand to 
rise and fall with the movements of the abdomen, the respirations may 
be counted, and the interference of the will, always called into play 
when attention is attracted to the breathing, be avoided. By this means, 
too. the pulse and breathing may be counted in succession, and compared. 
This precaution of holding the wrist should be observed even when, the 
respirations being audible, we prefer to count them by the ear. 

805. Number of the Respirations. — This is subject to at least as 
much variety as that of the pulse. The number of respirations in a 
minute is usually stated at 18, or about one to every four beats of the 
pulse. For the adult male the estimates of authors vaiy from 14 to 26 
in a minute. 

806. The respiration, like the pulse, varies in frequency with age, 
sex, posture, and time of day — with exercise, rest, and sleep. 

807. Age and Sex. — Quetelet obtained the folio wing results from 
about three hundred observations on males, and a smaller number on 
females : — 

Number of the Respirations. 



AGE. 


MALE. 


F KM ALE. 


At biith 


23 to 70 


27 to 68 


5 years 


32 




15 — 20 


16 to 24 


19 


20—25 


14 to 24 


17 


25—30 


15 to 21 




30—50 


11 to 23 


19 



808. The range of my own respiration, from my twenty-eighth to my 
thirtieth year, as founded on numerous experiments, with the seif-regis- 



184 SYMPTOMS A>~D SIGNS OF DISEASE. 

tering instrument, in different postures and under different circumstances, 
was 12 to 22. 

809. Vierordt obtained, as the result of observations on his own per- 
son, in the sitting posture, a maximum of 15, a minimum of 9, and an 
average of 12. Hutchinson, in rough and inexact experiments on 1714 
healthy males in the same posture, found a minimum of 6, and a maxi- 
mum of 41 ; while the greater number were found to breathe 20 times 
in the minute, and a very large proportion between 16 and 24 times. The 
recorded frequency of respiration in the persons of the principal experi- 
menters on that function ranges from 14 to 27. 

810. Posture. — The results of a large number of observations, made 
on my own person, by the self-registering instrument, were as follows: 
— For a pulse of 64 the respirations were, standing, 22 ; sitting. 19 ; 
and lying, 13. Hence the rule of the pulse — that the difference between 
standing and sitting is greater than that between standing and lying 
— is inverted in the case of the respiration. The respiration in the sit- 
ting posture, for different frequencies of pulse, ranged from 15 to 21. 

811. Period of the Day. — The rule of the pulse is also inverted in 
respect to the time of day ; for whereas the pulse becomes less frequent 
as the day advances, the lespiration becomes more frequent. For the 
same number of the pulse, there are about 18 respirations in the even- 
ing for 17 in the morning. The same rule obtains in disease in both 
sexes, even in those cases in which the pulse becomes more frequent in 
the evening. 

812. Sleep. — In a woman, setat. 27, Quetelet found the respirations 
to be, awake, 27 ; asleep, 21. In two young children the differences 
were 5 and 8 respectively. In his experiments the respiration was more 
affected by sleep than the pulse. 

813. The other causes which in health affect the frequency of the 
pulse, produce a like effect on the respiration. Thus, all causes which 
increase the frequency of the pulse and the force of the circulation, 
also augment the number of respirations, and the reverse. Exercise in- 
creases the number of respirations, rest diminishes them : heat increases 
and cold diminishes the frequency both of the pulse and breathing. Sleep, 
which lowers the pulse, has a still more marked effect on the breathing. 
The only exception to the rule is that of debility ; for debility without 
disease, provided it be not extreme, is accompanied by an infrequent 
pulse, while the number of respirations is increased in eveiy degree of 
debility. 

814. Proportion of the Respiration to the Pulse. — This has been 
variously estimated by authors, at 1 to 4, 1 to 4j, and at 1 to 5. But 
no dependence can be placed on these estimates, as they were formed in 
ignorance of the effect of posture on the breathing. In experiments on 
my own person, made with the self-registering instrument, the propor- 
tion has varied between 1 to 2*60 and 1 to 5'23 ; and in the sitting 
posture from 1 to 2*61 to 1 to 5*00. 



THE RESPIRATION AND THE PULSE. 185 

The chief causes of the different ratios of pulse and respiration are the 
posture of the body, the time of the day, and the number of the pulse 

itself. 

815. Posture. — For a pulse ot 64, the proportion, standing, was 1 
to 2' 95 ; sitting, 1 to 3 # 35 ; and lying, 1 to 4-97. 

816. Time of Bay. — The proportions morning and evening for the 
same frequency of pul-e are about 1 to 3*60 and 1 to 3*40. 

817. Number of the Pulse. — The ratio of the respiration to the pulse 
decreases as the pulse increases ; for a pulse of 54, being 1 to 3 ; for a 
pulse of 72, 1 to 4. Asa general rule, the number or* respirations in- 
creases with that of the pulse, but in a less rapid ratio, the proportion 
decreasing as the pulse increases. It is believed that these statements, 
founded on my own observations, will be found in the main correct. 

818. In disease the number of respirations varies within much wider 
limits than that of the pulse. The smallest number I have counted is 
6 in a female in a deep sleep, but not comatose, after attempting suicide 
by laudanum ; and I have counted as few as 10 respirations in a case of 
paralysis. On the other hand, I have reckonel as many as 44 in a case 
of phthisis. 73 in a case of paralysis agitans, and 140 in a case of hysteric 
asthma. Floyer met with 60 respirations in a case of suffocative catarrh, 
and in a case of inflammation of the lungs in a child : on the other hand, 
he counted as few as 7 in more than one attack of asthma. Dr. Graves 
has recoided as small a number as 12, and as many as 50, in cases of 
fever. 

819. Patio of the Respiration to the Pulse in Disease. — Floyer found 
it as high as 1 to 2 in a case of suffocative catarrh, and as low as 1 to 
14 in a case of asthma; Dr. Graves observed as high a proportion as 1 
to 2 in one case of fever, and as low a proportion as 1 to 20 in another. 
In the case of paralysis agitans alieady referred to, I counted a pulse of 
72 and 73 respirations : in the case of hysteric asthma, 144 pulses and 
140 respirations ; in a case of transposition of the heart, 32 respirations 
to 46 pulses ; and in a case of paralysis, 1 respiration to 6^ pulses. In 
a case of aneurism of the heart reported by Mr. Peacock there were 34 
respirations to 33 pulses. 

820. These remarkable variations in the number of the respirations 
as compared with that of the pulse are readily explained, if we reflect 
that the respiration is influenced by many other causes besides the 
quantity of blood sent to the lungs by the heart. Some of these are in- 
ternal, some external. The principal internal causes are the s f ate of the 
lungs themselves, and of their investing membrane. Among external 
causes are mechanical obstructions, such as the pressure of tumouis on 
the air passages, constriction of the chest, increased or diminished action 
of the muscles of respiration, &c. All these obstructions to the free play 
of the lungs quicken the breathing; and this, whether accompanied by 
a feeling of uneasiness or not, has been called dyspnoea. As this is the 
chief symptom of all diseases of the lungs, and a concomitant of a great 



186 



SYMPTOMS AND SIGNS OF DISEASE. 



I majority of diseases of the heart, its chief causes are here presented in a 

tabular form.* 

CAUSES OF INCREASED FREQUENCY OF RESPIRATION, OR DYSPNCEA. 

I. Quantity of blood in lungs increased. 

( Exercise, repletion, plethora (1st 

a. "With quickened circulation. - degree), inflammatory levers, hyper- 
( trophy of the right side of the heart. 

b. With obstacle to return of blood f Diseases of the mitral valve, pres- 



to the heart. 
1 1. Quality of the blood altered. 

a. More venous than usual. 

b. Red particles deficient. 

III. Deficiency of oxygen. 

a. Air pure, but small in quantity. 

b. Air defective in quality. 

IV. Mechanical obstructions. 



a. Of the air tubes. 



^ b. In lungs themselves. 

c. In pleural sac. 
\d. Caused by other organs. 
= a. In parietes of chest. 
x \b. In abdomen. 



"(sure on the pulmonary veins, &c. 

(Morbus coeruleus, &c. 
"(Anamiia, chlorosis. 

( Air rarefied by high temperature, 
"<or diminished atmospheric pressure. 
( Non-poisonous gases, as nitrogen 
\and hydrogen. 

( Diminished size from thickening of 
< walls, from pressure, and from accu- 
mulations of mucus. 
( Congestion, hepatization, oedema, 
-I tubercle, &c. ; emphysema, dilated 
(bronchi, vomica?, &c. 
( Hydrothorax and pneumothorax, 
"(pleuritic affections and adhesions. 
J Enlargement of the heart or large 
"(vessels, aneurismal tumours. 
( Malformations and distortions, ossi- 
"(fication of cartilages, &c. 
f Enlarged viscera, tumours or drop- 
"(sical effusions. 



State of the muscles of respiration, 
a. Paralysis (partial). 



Pain 



i Injuries of the spinal marrow, in the 
"(neck, &c. 

( From fatigue, from exhaustion, after 
b. Debility. - severe febrile affections, and at the 

(approach of death. 

( In intercostals, diaphragm, or ab- 
1. In muscles. 4 dominal muscles, those acting which 

(are free from pain. 
( In the abdomen in peritonitis, in the 
f 2. In surrounding parts. - chest in pleurisy, the muscles that 
(cause least pain acting alone. 

d. Spasm. Tetanus, hydrophobia, &c. 

e. Other forms of augmented inner- ( Strong mental emotions: hysteria, 

vation. "(asthma. 

821. The chief causes of diminished frequency of respiration are 
sleep and coma, however produced, whether by narcotics or by cerebral 
pressure. The respiration, therefore, is slow in apoplexy, and in nar- 
cotic poisoning. 

822. Other characters of the respiration, besides increase of number, 
merit attention ; as the full or deep, the small or feeble, the equal or 



* A similar table is given by Dr. Williams in Lib. Pr. Med. vol. iii. p. 25. 



THE RESPIRATION" IN DISEASE. 187 

unequal ; the regular or irregular ; the short, quick, and catching ; the 
long, the labouring ; the thoracic, abdominal, and diaphragmatic. 

823. A peculiar respiration has been observed to be associated with 
fatty degeneration of the heart. The patient, after remaining in a state 
of apncea for a quarter of a minute or more, has a feeble respiration 
followed by a succession of breathings, increasing in force up to a 
maximum of strength, and then as gradually diminishing. This pheno- 
menon has been described by Drs. Cheyne, Stokes, and feibson. 

824. The number of respirations taken by itself is of comparatively 
little value ; it is only when combined with observations on the pulse, 
or examinations of the chest by percussion and auscultation, that we 
learn its real significance. Thus, a frequent respiration, taken alone, 
may arise from any one of the many causes specified in the table ; but 
coupled with an infrequent pulse, in the ascertained absence of visceral 
disease, would strongly indicate great debility, or, in the absence of this, 
hysteria. On the other hand, au infrequent pulse and respiration com- 
bined would as probably arise from some disease or injury of the brain, 
or of the upper portion of the spinal cord. Again, a frequent and quick 
respiration, in the absence of visceral disease, and attended by acute 
pain of the walls of the chest or abdomen, is explained by the existence 
of that pain, whether its seat be the muscles or the peritoneum. 

825. Important indications may also be obtained by noting the 
number of respirations day by day in acute diseases. In pneumonia, for 
instance, a daily diminution in the number, with or without a similar 
change, in the pulse, gives good hope of recovery ; in apoplexy or in 
narcotic poisoning, on the contra 1 y, an increase in the number, especially 
if attended by increased frequency of pulse, may be considered a good 
symptom. bo in convalescence from fever, with great debility, a 
diminished frequency of respiration, with increase in the number of the 
pulse, is a sign of returning strength. 

826. In using these, as well as the less important symptoms and 
signs of disease, the observer should be on his guard against the common 
error of trusting too implicitly to any one sign, however valuable, to 
the neglect of others which are capable of affording useful information. 
In diseases of the chest, for instance, neither stethoscopic signs, nor respi- 
ration, nor pulse alone, can furnish the practitioner with all the infor- 
mation which he wants ; but if, knowing the exact value of each of 
th^se signs and the fallacies attaching to each, he uses all of them at the 
same time, there are few difficulties in diagnosis which he will not be 
able to overcome. 

6. Other Symptoms and Signs of Disease. 

827. Besides the signs and symptoms minutely examined in the first 
five divisions of this chapter, there are many others of which it is 
easier to recognise the importance than to arrange them in a manner 
free from objection. Some of them, as the expression of the counte- 



188 SYMPTOMS AND SIGNS OF DISEASE. 

nance, the appearance of the tongue, and the presence or absence of 
pain, are subjects of observation and inquiry in every case of disorder 
or disease without exception ; while others, as the appearance of the 
sputa, or of the discharges from the bowels, are noted only, or chiefly, 
in diseases of the lungs, or of the primse vise. Yet these symptoms of 
larger import often associate themselves very naturally with others of 
very limited application — e.g., the appearance of the tongue with that 
of the lips and gums in anaemia ; so that it seems reasonable to group 
them together, and to treat them in connection with each other. Ac- 
cordingly, the remaining symptoms and signs will be examined in this 
section under the distinct heads of — 1. The organs of digestion. 2. 
The organs of circulation. 3. The organs of respiration. 4. The 
urinary and genital organs. 5. The nervous system. G. The tempe- 
rature of the body. 7. The expression of the countenance, and the 
condition and attitude of the body. 

828. [1.) The Organs of Digestion. — The condition of the ali- 
mentary canal is revealed to us in part by the state of the tongue ; in 
part by alterations in the functions of the stomach and intestines, such 
as nausea, vomiting, and purging; and in part by the character of the 
matters voided from the stomach and bowels. 

829. The value of the tongue as a symptom or sign of disease, and 
an aid in diagnosis and prognosis, will be understood if it is borne in 
mind that it consists of a dense mass of muscular fibre, largely sup- 
plied with blood, covered with a secreting membrane, and lying in a 
bath formed of the secretions of the mouth and salivary glands. It 
may, therefore, be expected to indicate the state of the muscular and 
nervous system, of the circulation, of the secretions generally, and espe- 
cially of those of the alimentary canal, to which it belongs by continuity 
of membranous covering, and as subserving the function of mastication. 

830. The tongue does not present the same appearance in all healthy 
persons. In some it is habitually clean, in others slightly furred; in 
some florid, in others pale, in some compact and firm, in others flaccid 
and indented by the teeth ; in some it is protruded in a relaxed state, 
in others strongly contracted and drawn to a point. Even in the most 
healthy persons it is covered with a thin white fur in the morning 
before taking food, and those who sleep with the mouth open awake 
with a perceptible dryness of tongue. 

831. In disease, the tongue presents a variety of appearances. As to | 
size, it is swollen in inflammation of the organ itself, in severe diseases 
of the adjacent parts, in salivation from mercuiy, and in malignant 
disease ; on the other hand, its size is diminished when there is much 
emaciation. The swollen tongue is often indented by the teeth, an ap- 
pearance which it also wears in that relaxed and flabby state that 
often accompanies great debility. Its form varies with the mode in 
which it is protruded ; but as a general rule, it is small and pointed in 

" irritation," broad and flabby in exhaustion. The temperature of the 



THE TONGUE. 189 

tongue is low in syncope and apncea, and, in common with the breath, 
is very low in epidemic cholera. Its colour coincides, to a certain ex- 
tent, with that of the general surface, being florid in plethora ; pale after 
profuse discharge-, in anaemia and allied states of system, and in many 
chronic wasting maladies; and livid in apnoea and in certain diseases of 
the heart and lungs which greatly impede respiration. Its colour also 
depends on the state of the digestive organs. Thus it is universally 
red, or red at the tip, or at the edges, or in both situations, in some 
cases of acute inflammation of the mucous membrane of the stomach 
and bowels. It is also very red and tender in some cases of scarlatina, 
and in continued fevers after the disappearance of the fur. A smooth 
red tongue, sometimes known as a 'glazed' tongue, is often present 
in fever accompanied by great irritation of the stomach and bowels, and 
in idiopathic affections of those organs. In acute inflammation of the 
throat, the tongue also assumes a deep red colour. In poisoning by the 
mineral acids it is stained of characteristic colours, and has its epithelial 
covering partially or wholly removed. 

832. Much importance attaches to the state of the tongue in respect 
of moisture. As the tongue of a healthy person is kept moist by the 
secretions of the mouth, and by the saliva, it becomes dry when those 
secretions fall short of the quantity required to supply the loss by eva- 
poration and that which from time to time passes down the gullet in 
the act of swallowing. It is obvious, therefore, that the tongue must 
afford a valuable index of the state of the secreting organs, and of the 
condition of the circulation, as promoting or retarding their proper 
functions. Accordingly a dry tongue, such as exists in inflammatory 
and febrile states of system, indicates a state of circulation unfavourable 
to secretion in other organs as well as in the tongue and mouth. On 
the other hand, a moist tongue indicates a favourable state of the secre- 
tions geneially, and the absence of any high degree of inflammation or 
fever ; and it is obvious that a transition from a dry to a moist tongue 
must always be a favourable sign. Hence, in cases of fever, the phy- 
sician carefully inspects the tongue, examines it by the touch, and hails 
a moisture appearing at the edges, and gradually extending to the centre, 
as the sign of a freer state of all the secretions, and a mark of approach- 
ing convalescence. Again, a moist and flabby tongue, indented by the 
teeth, is justly regarded as a sign of want of tone and vigour, and an 
indication cf a state of circulation favourable to secretion from other 
organs as well as from the mouth. 

833. A fur collects on the tongue in almost all severe diseases: — a 
white creamy fur in the first stage of fever, in catarrh, in quinsey, in 
most severe inflammations, and in acute rheumatism ; a thick brown 
or black coating in more advanced stages of fever ; or the tongue is dry, 
parched, and tender. A thick, black, dry fur, with black sordes about 
the teeth, is seen in the typhous stage of fever, and in low typhous 
conditions of the system, coinciding with a highly impure state of the 
blood, with unhealthy secretions, and fetid discharges from the bowels. 
A brown dry fur exists in cases of local irritation, the tongue becoming 



190 SYMPTOMS AND SIGNS OF DISEASE. 

moist as the irritation subsides. In jaundice, the fur is sometimes 
tinged with bile, and in scurvy it is blackened by effused blood. In 
dyspepsia, the appearance of the tongue is very variable. Sometimes a 
thick fur collects at the base, while the tip and edges are bright red ; 
sometimes the fur extends over the whole surface, and is accompanied 
by indentations of the teeth, by partial abrasions of the epithelium, and 
by deep cracks, which are often strongly marked in spirit drinkers. 
Deep foul ulcers of the tongue, with hard bordeis, are common conse- 
quences of syphilis. In constipation the tongue is sometimes covered 
with a brown fur ; but it may present no unusual appearance. 

834. There is a very peculiar and characteristic appearance of the 
tongue in scarlatina. The papillae, elongated and florid, protrude 
through a white coating of fur ; or, the tongue being bright red and 
free from fur, the papillae appear distinct on the red ground. In the 
first case the tongue closely resembles a white, in the second a red, 
strawberry. 

835. In common with the lining of the mouth and throat, the tongue 
may be the seat of small superficial ulcers, known as aphtha. These 
are common in infancy, when they constitute the " thrush ;" also in 
the last stage of pulmonary consumption, and towards the fatal termi- 
nation of other chronic visceral diseases. 

836. The mode in which the tongue is protruded is often charac- 
teristic. Sometimes it is tremulous in extreme weakness, in cases of 
idiopathic fever with debility, and under the influence of fear. It is 
protruded with difficulty when dry ; slowly and hesitatingly in diseases 
accompanied by stupor, in which case it is withdrawn after an interval, 
and as if in consequence of deliberation. In partial paralysis the tongue 
is protruded either towards the sound or the affected side of the face. 

837. The gums afford signs rather of the state of the circulation than 
of the digestive organs. They are florid in plethora; pale in anaemia ; 
livid when respiration is much impeded ; swollen and dark, and apt to 
bleed on the slightest touch, in sea and land scurvy ; swollen with an 
inflamed liue in mercurial salivation ; marked with a blue line in poison- 
ing by lead. 

838. The lips and membrane of the mouth, like the gums, indicate 
the state of the circulation. They are pale in anaemia; dry and parched 
when the tongue is similarly affected, the seat of aphthous ulcers in 
young children, in consumption, and towards the close of febrile and in- 
flammatory affections. An herpetic rash on the lips is a common and 
characteristic accompaniment of severe catanh. 

839. The teeth afford some useful indications. During the first den- 
tition they are the souice of much suffering, of >evere febrile symptoms, 
of marked disturbance of the functions of the alimentary canal, of con- 
vulsions, and of eruptive diseases. In later life, sound teeth are an in- 
dication of vigour, and their earlv decay is one of the marks of a feeble 



THE TASTE AND APPETITE. 191 

or scrofulous constitution. Caries of the teeth may, however, be in- 
duced by habitual indigestion, by the excessive use of sweets and acids, 
and by the abuse of mercury. Workmen who handle mercury are also 
subject to chipping of the teeth. The teeth grow loose in scurvy, and 
during salivation with mercury. They are covered with dark brown 
or black sordes in continued fevers and in typhous states of system. 
Grinding of the teeth in sleep is common in children suffering from 
worms or other intestinal irritation , and chattering of the teeth accom- 
panies the severe shivering fits that usher in many febrile disorders, and 
form part of the paroxysm of ague. 

840. The fauces and tonsils are subject to chronic inflammation and 
swelling, and the uvula to relaxation, which may be taken to indicate 
want of constitutional vigour. The same parts are the seat of inflam- 
mation in scarlet fever, diphtheria, and severe attacks of catarrh ; and 
of ulceration in secondary syphilis. The tonsils are liable to intense in- 
flammation and great enlargement in quinsey, and they are the seat of 
a painful chronic irritation in persons who use the organs of speech 
unskilfully. 

841. The Saliva. — An increased flow of saliva sometimes occurs as 
the result of irritation of the salivary glands, in inflammation of the 
mouth and parts adjacent, sometimes as the consequence of dentition in 
children, and of unsound teeth in the adult ; sometimes, again, as an 
effect of certain active medicines, such as mercury, iodine, antimony, 
and their preparations, of prussic acid and digitalis. An increased flow 
of saliva is not uncommon in pregnancy. Mercurial salivation is at- 
tended by soreness of the gums, a brassy taste, and a peculiar fcetor, 
which serve to distinguish it from mere increase of saliva ; also by a fe- 
brile disturbance known as the mercurial ercthysm. Frothing at the 
mouth, due in part to increase of saliva, and in part to increased mucous 
discharge from the air-passages, is a common symptom of epilepsy and 
hydrophobia, in the first of which diseases the froth is, as it were, 
churned out of the mouth by convulsive movements of the muscles of 
the tongue, mouth, and lips ; while in the second it is spit out between 
the closed teeth. 

842. The Taste. — The sense of taste is impaired in all diseases in 
which the tongue becomes dry or furred ; and probably in apoplectic 
seizures. A bitter taste is often present in jaundice, and on waking in 
the morning in persons suffering from feverish attacks, or from severe 
dyspepsia ; and it may be caused instantaneously by strong mental 
emotion. Consumptive patients often complain of the salt taste of their 
sputa, and a putrid taste is present in diseases in and about the mouth 
attended by decomposition. Some dyspeptics also complain of a taste as 
of rotten eggs; and a biassy taste is one of the signs of mercurial sali- 
vation. It is probable that the sense of taste is subject to illusion in 
madmen who swallow their vomited matters, urine, and faeces. 

843. The Appetite. — Loss of appetite (anorexia) and distaste for food 
(nausea) are among the earliest symptoms of indisposition, and the most 



192 SYMPTOMS AXD SIGNS OF DISEASE. 

constant attendants of severe illness: on the other hand, a restored appe- 
tite is among the earliest indications of convalescence. A foiling appe- 
tite, again, is an unfavourable symptom in chronic maladies, and in ad- 
vanced age ; but it may be caused in persons not suffering from disease 
by want of exercise and fresh air, and by depressing passions. A vora- 
cious appetite (bulimia) is an occasional result of irritation of the stomach, 
or of intestinal worms; and it is sometimes a disease of itself, not easily 
traced to its true cause. It is often present in the mesenteric disease of 
children, in whom that part of the food which should have nourished 
the body is prevented from entering the lacteals. A voracious appetite 
is also common during established convalescence, obviously as a means 
of repairing the wasted body. Intense hunger is one of the after-effects 
of Indian Hemp. In some cases it is associated with frequent vomiting 
of food, as in inflammation attacking the stomach near the pylorus. A 
depraved appetite (pseudorexia; occurs in pregnant females, in chlorosis, 
and in hysteria, and in some forms of insanity. 

844. Thirst is a common symptom of disease. It is present in active 
inflammations, and in violent febrile attacks, in consequence, probably, 
of the tongue, mouth, and throat partaking of the vascular fulness of 
the whole system, and suffering from an inconvenient and distressing 
dryness. It also occurs in accidents and diseases attended by sudden loss 
of blood, or rapid outpouring of some important secretion, as in diarrhoea, 
dysentery, and cholera; in diabetes; in some forms of dropsy; and in 
cases of phthisis attended with profuse perspiration. In healthy persons 
it always follows strong exercise, and it is the most urgent suffering of 
the soldier on the march, and of the wounded on the field of battle. It 
is also a consequence of the excessive use of saline matters, as in] ] the 
sailor fed on salt meat, and, in a less degree, of condiments to excess; 
and it is a leading symptom of irritant poisoning. An excessive desire 
for liquids is known as polydipsia. 

845. The Odour of the Breath. — Liquids having a strong and peculiar 
odour, or imbibing it from food with which they are mixed, pass readily 
from the stomach into the circulation, and being eliminated by the lungs, 
taint the breath. The odour of spirits, due to this cause, sometimes 
enables the medical man to distinguish the effects of intemperance from 
an apoplectic seizure. A foul breath is among the symptoms of dys- 
pepsia, of that unhealthy condition of body known as cachexia, of sali- 
vation, of advanced stages of fever, of scurvy, and generally of inflam- 
mations in and about the mouth, attended by decomposition ; or followed 
by gangrene. It is accordingly present in gangrene of the mouth, and 
in caries of the teeth. On the other hand, an extremely offensive breath 
is sometimes traceable to gangrene of the lungs. The breath has been 
observed to have the odour of honey in saccharine diabetes. 

846. Vomiting as a symptom of disease can only be duly appreciated 
by bearing in mind that the stomach is not merely the chief organ of 
digestion, but a viscus in close nervous relation with the brain, heart, 
and lungs. Vomiting therefore may be a symptom of disorder or disease 






VOMITING AND VOMITED MATTERS. 193 

in the stomach, as well as a consequence of severe injury or disease of the 
more important organs of the body, or of shocks to the nervous system. 
Among the causes affecting the primse vise may be mentioned, simple 
overloading of the stomach ; irritating food ; inflammation of its mucous 
membrane, by whatever cause produced ; obstruction to the passage of 
the food through the pylorus, as in cancer of the stomach ; permanent 
obstruction to the passage of the fasces through the intestines, as in ileus 
and strangulated hernia ; and inflammation of the entire alimentary canal, 
as in English and Asiatic cholera. Vomiting is also a common effect of 
irritant, aud narcotico-acrid poisons, and sometimes attends poisoning by 
the pure narcotics, especially carbonic acid. It is also a common effect 
of chloroform. To the more indirect and remote causes of vomiting be- 
long concussion of the brain, the condition of the brain preceding an 
apoplectic seizure, and inflammation of its substance and membranes. 
Vomiting, again, accompanies the passage of gallstones, and of renal cal- 
culi, and severe inflammation of the heart, and of the womb. It is also 
very common in delicate females, and is one of the most constant symp- 
toms of pregnancy. Lastly, vomiting is often amongst the earliest pre- 
monitory symptoms of severe attacks of the febrile exanthemata, and 
particularly small-pox. 

In vomiting dependent on diseases of the stomach and bowels, it is im- 
portant to note the time after a meal at which it occurs. As a general rule, 
If it follows immediately, or quickly, on the reception of food, it is attribut- 
able to inflammation of the mucous membrane of the stomach itself. 
In ulcers of the stomach it is retained longer. If the food is rejected 
after an hour or more, the cause may be traced, with great probability, 
to the pylorus or duodenum. If the vomited matters do not consist of 
food, this inference will not hold good. When, instead of a single act 
of vomiting ushering in an attack of illness, the vomiting recurs again 
and again, it must be looked upon as an unfavourable complication, ex- 
cept in pregnant women. 

847. Vomited Matters. — We are often assisted in our diagnosis by 
examining the matters rejected from the stomach. The food is returned 
nearly unchanged in irritation, inflammation, ulceration, or obstructive 
disease of the stomach itself, in pregnant women, in vomiting due to 
remote constitutional Causes and nervous shocks, and under the opera- 
tion of many irritant poisons. Clear acid liquids are vomited after an 
interval of from half an hour to two hours or more in the disease known 
as gastralgia or gastrodynia. Bile regurgitates from the duodenum, and 
is discharged by vomiting, in functional and organic diseases of the liver. 
Blood is often discharged in very large quantities in the disease known 
as hsematemesis ; generally of a dark colour, clotted, and mixed with 
food ; rarely of the florid hue of haemoptysis. The blood so discharged 
may flow from the general surface of tiie stomach, or from one or more 
ulcers in the mucous membrane ; or it may regurgitate through the 
pylorus from the duodenum. A discharge of a large quantity of florid 
blood may be the result of an aneurism bursting into the stomach. A 
brown grumous matter, often mixed with blood, is rejected from the 






194 SYMPTOMS AND SIGNS OF DISEASE. 

stomach in poisoning by the corrosives. Vomiting of purulent or muco- 
purulent matter points to the rupture of an abscess of some neighbour- 
ing viscus. Feculent vomiting is a symptom of 
mechanical obstruction of the lower portion of the 
intestinal canal, or of a fistulous communication 
between the stomach or upper part of the small 
intestines and the colon. In a highly acid state of 
the contents of the stomach, a scanty mucus, or a 
clear acid liquid, abounding in small round black 
flakes, is sometimes vomited. These matters, when 
phced under the microscope, are found to contain 
the vegetable growths described by Goodsir as Sar- 
cina ventricv.li .(Fig. 47.) 

848. The bowels are variously disordered ,* sometimes confined from 
torpor, from the absence of their natural stimulus, from mechanical ob- 
struction, or from the operation of the poison of lead ; sometimes relaxed, 
from inflammation of the mucous membrane, whether caused by previous 
constipation, unwholesome food, purgative medicines, or irritant poisons. 
Diairhcea is also a constant consequence of ulceration of the intestines in 
typhoid fever ; it is common in pulmonary consumption, uniformly present 
in advanced stages of tabes mesenterica, and very prevalent during the 
heats of summer. It is an occasional consequence of a change of residence 
from cold to hot climates, and from low situations to elevated ones, 
fetiong mental emotions also sometimes give rise to diarrhoea. In union 
with vomiting it constitutes English and Asiatic cholera, and a leading 
symptom of irritant poisoning. Frequent and scanty discharges of mucus, 
pus, or blcod, with great tenesmus, mark the disease known as dysentery. 

849. The alvine discharges may consist of mucus, tenacious lymph, 
or pus, as in inflammations of the mucous membiane of the canal, the 
nature of the secretion depending on the degree of irflammation ; or they 
may consist of blood poured out by the vessels of the intestines generally, 
by those of the large intestines exclusively, or by the f nlai gel veins of the 
rectum f piles). In tabes mesenterica they consist chiefly of ill-digested 
food, and in disease of the pancreas they contain an unusual quantity of fat. 

850. The evacuations may 1 e pale from the absence of bile ; unusually 
yellow from its excess ; green, as often happens in children ; dark and 
offensive, from the long retention of feculent matter, or fiom morbid 
secretions of the liver: dry from long retention, and in detached massis 
known as scybala. They assume a light yellow colour under the use of 
mercurial preparations ; a green colour from the mineral acids in large 
doses ; preparations of iron turn them black, as does also the admixture of 
blood in large quantity. 

It is important to distinguish those discbaiges which flow from the 
general suiface of the intestines from such as are the product of disease 
in the rectum. When, therefore, pus or blood is discharged with the 
motions, and the symptom is not promptly relieved by proper aperient 
medicines, the rectum should be examined for piles or fistula, or (if 



ORGANS OF CIRCULATION — THE VEINS. 195 

florid Wood is poured out in considerable quantity) for a bleeding artery 
laid bare by ulceration. 

851. We are often assisted in our diagnosis by comparing the dis- 
charges from the stomach with those from the bowels. Thus, obstinate 
constipation, with vomiting of feculent matter, implies mechanical ob- 
struction, as in strangulated hernia; while vomiting of feculent matter, 
mixed with imperfectly digested food (lientery), goes far to justify the 
inference that a fistulous opening exists between the stomach or begin- 
ning of the small intestines and the colon (ileo-colic fistula). 

852. The Organs of Circulation. — The most important symp- 
tom and sign of disease connected with the circulation is the pulse, which 
has been minutely examined in a former division (4) of this chapter ; 
and some indications of the state of the capillary circulation have also 
been considered when speaking of the gums, lips, and lining mem- 
biane of the mouth. Similar indications of the state of the circu- 
lation through the small-vessels, and of the lull or empty state of 
the vessels generally, are afforded by the appearance of the skin, which 
is pale after losses of blood, in ansemia, in leucocythemia, and in analo- 
gous states of system, universally florid in plethora, of a brighter or 
duskier red, in patches of greater or less extent, in the febrile exan- 
themata, livid in diseases of the heart and lungs attended with imperfect 
aeration of the blood, and yellow in jaundice, from the retention in the 
blood of bile which ought to be eliminated by the liver. The languid 
circulation of old age is marked by dark discoloration of the skin of the 
legs ; and habits of intemperance often betray themselves by the appear- 
ance of the skin of the face, permanently mottled with streaks and spots 
of dark-red on a yellow ground. In extreme debility, such as occurs in 
sea and land scurvy, and in the typhous stage of continued and remittent 
fevers, the small vessels often give way, and the blood is shed into 
the surrounding tissues. When the effusion is large, it is called an 
extravasation; when it forms small round spots in the skin, these are 
balled petechias. Extravasations and petechia? do not disappear en pres- 
sure; but the redness due to plethora, inflammation, or congestion, 
readily disappears on pressure, but quickly returns on its removal. 

853. The veins, by their distended and swollen state, sometimes supply 
useful aids to diagnosis. When, for example, the sounds heard over the 
region of the heart lead us to inter valvular disease, but leave us in 
doubt as to the particular valve affected, a visible pulsation in the 
jugular veins accompanying each beat of the heart indicates regurgita- 
tion of the blood through the imperfectly closed tricuspid valve. When 
the pulsations are very distinct, we infer that the walls of the right 
ventricle are thickened. In very rare cases, a visible pulsation is com- 
municated to the veins by the transmission of the heart's impulse through 
the capillaries. This is called the venous pulse; and indicates an un- 
usually strong action of the heart. This true venous pulse requires to 

■ be distinguished from the lifting of a vein by the force of the artery lying 
beneath it. The superficial veins sometimes become greatly distended 



196 SYMPTOMS AND SIGNS OF DISEASE. 

and highly varicose from the closure, by pressure or disease, ot some 
deeper-seated venous trunk. 

854. (3.) The Organs of Respiration. — Though the number of 
the respirations, and the proportion which they bear to the pulse, as well 
as the respiratory movements generally, have been minutely examined 
in a former part (5) of this chapter, several symptoms and sigDs of disease, 
due to disturbance in the functions of the lungs, remain to be considered. 
Certain respiratory movements, for instance, such as sighing, yawning, 
sneezing, and coughing, to which maybe added the noisy inspiration known 
as stertor, deserve notice, as well as the changes which the pulmonary 
secretions 'undergo in disease, and the odour and temperature of the 
breath. The signs derived from the altered character of the respiratory 
movements may be treated under the two heads of noisy inspiration and 
noisy expiration. 

855. Noisy Inspiration. — In healthy persons the air is drawn into 
the chest, and expelled from it noiselessly ; but there are diseases which 
are accompanied and characterised by peculiar inspiratory sounds. The 
long loud whooping inspiration following the complete emptying of the 
lungs by a succession of violent expirations, or coughs, is the familiar 
pathognomonic sign of whooping cough ; laryngismus stridulus is recog- 
nised by the peculiar crowing chaiacter of the inspirations ; and croup 
by a similar inspiratory sound compared to the crowing of a cock. At- 
tacks of spasmodic and humoral asthma, again, are marked by the loud 
wheezing or whistling which accompanies each drawing in of the breath. 
Stertor, stertorous breathing, or snoring, is another form of noisy inspi- 
ration which owes its origin to the napping of the soft palate when in- 
active, as in sound sleep, or paralysed, as in cerebral congestion. Accord- 
ingly it is present in apoplexy, and in compression and concussion of the 
brain ; and is one of the group of symptoms known as coma. Sigh- 
ing and yawning may be classed under this head. They aie forms of 
deep and audible inspiration, which, as a general rule, indicate the pre- 
vious imperfect performance of the function of respiration, through de- 
ficient nervous power ; from congestion of the lungs ; or from a slight 
mechanical impediment to the complete expansion of the chest. Asa 
general rule, sighing is expressive of emotion or intense occupation of 
the mind, and yawning of bodily fatigue. Yawning is also present in 
many nervous affections falling short of well-defined disease, and it attends 
the accumulation of urea in the blood. In the congestion of the lungs 
which follows recovery from asphyxia, after fainting fits, and during hys- 
terical attacks, sighing and yawning are common occurrences. Among 
mechanical impediments inducing yawning or sighing as supplementary 
to the ordinary movements of respiration, may be specified the restraint 
of stays in women, and in either sex the accumulation of flatus in the 
stomach hindering the downward movements of the diaphragm. Either 
of these mechanical impediments may bring on hysterical paroxysms in 
persons predisposed to them. Another foim of noisy inspiration is hic- 
cough. This is a short inspiratory movement, which affects chiefly the 
diaphragm. It is nearly allied in character to that common expression 



NOISY EXPIRATION. 197 

of grief, sobbing. Hiccough is often experienced to a painful degree in 
the act of eating, when the food is swallowed hastily. It is also a symp- 
tom of inflammation of the diaphragm, or of tho>e viscera, or parts of 
viscera (such as the liver, pancreas, duodenum, or cardiac extremity of 
the stomach), which are in contact with it, or lie adjacent to it ; and it 
is common in diseases of the kidney. Tumours pressing on thepneumo- 
gastric nerve are sometimes the cause of obstinate hiccough. It accom- 
panies the feculent vomiting of strangulated hernia, and often occurs 
towards the termination of many acute maladies, when it must be looked 
upon in a very unfavourable light. 

856. Noisy Expiration. — Sneezing and coughing are the two forms 
of noisy expiration, requiring notice as symptoms and signs of disease. 
Sneezing is a violent expulsion of air through the nostrils, following a 
deep and full inspiration. It either serves to clear the nostrils of some 
cause of irritation, or it marks the swollen and painful state of the lining 
membrane which ushers in attacks of catarrh and of measles. It is a 
symptom of longer continuance in the disease known as hay -asthma. It 
is also one of the group which marks the poisonous action of iodide of 
potassium. In common with other violent movements of the muscles 
of respiration, it may occur in hysteria. Coughing is a violent expira- 
tory effort by which the air-passages are freed from offending matters, 
as the nostrils by sneezing. The contents of the air-tubes thus expelled 
are said to be expectorated, and the act of expulsion is called expectora- 
tion. The matteis themselves are known as sputa. 

There are many different kinds of cough. A cough may be dry, or 
unattended by expectoration ; or moist, that is to say, accompanied by 
sputa. The dry cough may be due to irritation of the pulmonary branches 
of the pneumo-gastric nerve, or to the pressure of tumours and morbid 
growths on some part of the air-passages. Hence a dry persistent ring- 
ing cough will sometimes indicate aneurism of the aorta. A dry cough 
is also present in the early stage of inflammations of the air-tubes, when 
the blood vessels are in a state of fulness unfavourable to secretion. This 
happens at the onset of attacks of catarrh, influenza, and croup, and in 
the first stage of humoral asthma. A dry cough is also one of the results 
of dyspepsia, of obstinate constipation, and of intestinal worms; and a 
loud, dry, barking cough is recognised as a symptom of hysteria. The 
cough in incipient phthisis is either dry or attended with scanty expec- 
toration on rising in the morning or at distant intervals. An inflamed 
state of the fauces, with enlarged tonsils and relaxed uvula, is another 
cause of a dry cough. Inflammation or ulceration of the larynx and 
trachea also gives rise to a troublesome dry cough, or one attended with 
very scanty expectoration. When the seat of the disease is the upper 
pait of the larynx, the dry cough is accompanied by a hoarse voice. A 
short, dry cough, attended with acute pains in the side, is one of the 
symptoms of pleurisy. A dry cough coming on in paroxysms is called 
a spasmodic cough, and may be often traced to inflammation of the 
liver, to biliary obstruction, or to disease of some viscus situate near 
the diaphragm. But coughs accompanied by free expectoration, when 



198 SYMPTOMS AMD BIGNS OF DISEASE. 

occurring in paroxvsms. are also termed spasmodic. A moist cough, or 
a cough accompanied by expectoration, is more common than the dry 
cough. Such a cough is present in catarrh, in bronchitis, in confirmed 
phthisis pulmonalis, in whooping-cough, in pneumonia, in gangrene of 
the lungs, and in haemoptysis. 

857. Hie Expectoration, or Sputa. — The matters coughed up from 
the lungs often furnish important information ; but to interpret them 
aright, we must bear in mind the fact, that substances spit out, or 
otherwise rejected from the mouth, may consist of the secretions of the 
mouth and throat, of the nostrils, or of the lung>, as well as of the 
secretions and contents of the stomach ; and it is not always easy to 
ascertain, from the descriptions of a patient, which of these parts has 
supplied the matters submitted to inspection. When, for instance, the 
fluid consists wholly or chiefly of blood in large quantity, it is not always 
easy to ascertain whether it came from the lungs by an almost imper- 
ceptible cough, or from the stomach by an easy act of vomiting; when, 
on the contrary, the quantity of blood in the sputa is small, it may be- 
equally difficult to determine whether it was hawked from the throat 
or coughed from the lungs. Young children generally swallow expec- 
torated matters. 

858. Having ascertained that the matters submitted to examination 
come from the lungs, we should consider their quantity, both absolutely, 
and relatively to the time occupied in their discharge, as well as their 
quality. As a general rule, a continuous and abundant expectoration, 
especially if coughed up with ease, may be regarded as favourable, as 
far, at least, as the present state of the patient is concerned. Such an 
expectoration exists in the moist stage of common colds, in chronic bron- 
chitis, in confirmed phthisis, and in whooping-cough. 

859. On the other hand, a scanty expectoration ushers in all acute 
attacks of disease of the lungs, though it also exists in the first stage of 
a common cold, and throughout the incipient stage of pulmonary con- 
sumption. It marks the first onset of a fit of humoral asthma, and the 
first stage of pneumonia. Again, a transition from a scanty to a more 
abundant secretion may be looked upon as a favourable symptom, just 
as the reverse indicates a relapse or increase of disease. When a scanty 
secretion, coughed up with difficulty, is streaked with blood, it may be 
taken as evidence of great congestion, or active inflammation of the 
lungs. Again, a copious sputum brought up in one act or fit of cough- 
ing has a significance of its own. It shows either a previous accumu- 
lation of the discharged matter in some cavity of the lungs, or in some 
neighbouring viscus, or a very rapid outpouring of the same from a 
considerable extent of mucous membrane of the lung itself. 

860. The character of the sputa often supplies an important aid to 
diagnosis ; the changes which occur in the course of the same illness 
being specially deserving of attention. The sputa may consist of un- 
mixed mucus of various degrees of consistence (as in catarrh, bronchitis, 



SPITTIXG 0F BL oOD — OTHEE SPUTA. 199 

and pneumonia) ; of a thin watery mucus (in some ca?es of early 
phthisis) ; of a tenacious, gelatinous mucus, mottled with small round 
brown or black spots, and full of air-bubbles (in the stage of humoral 
asthma immediately following the dry stage) ; of a stringy tenacious 
brown or rust-coloured mucus (in the first stage of pneumonia) ; of 
mucus tinged or streaked with dark blood (in the acme of a fit of hu- 
moral asthma, in acute pneumonia, and in some cases of phthisis pul- 
monalis) ; of mucus blended with pus (in fully developed catarrh, in 
bronchitis, and in confirmed phthisis). Again, the expectorated matters 
may be wholly or chiefly purulent, the contents of a cavity suddenly or 
gradually discharged, or of the sac of the pleura, through a fistulous 
opening into the lungs ; or of an abscess in the liver, in this latter case 
deeply tinged with bile. The sputa have sometimes an extremely offen- 
sive odour, arising from the decomposition of the retained secretions, or 
from gangrenous destruction of the substance of the lung. Expectora- 
tion of blood, in larger or smaller quantity, is a common occurrence in 
disease of the heart and lungs. 

861. Spitting of Blood. — There are few cases of pulmonary con- 
sumption in which this symptom does not happen; and it always 
furnishes a strong presumption in favour of the existence of that disease. 
A scanty expectoration of blood may, however, occur in pneumonia, in 
acute bronchitis, and in the fit of asthma ; and a copious and rapid dis- 
charge of blood by coughing in the rare disease known as bronchial 
polypus, and in aneurismal tumours communicating with the air- 
passages, as well as in confirmed consumption. The colour of the blood, 
the matters with which, if not pure, it is mixed, and the mode of its 
discharge, should always be carefully inquired into, as it may be of great 
importance to distinguish copious haemorrhage from the lungs, in 
haemoptysis, from equally copious discharges of blood in hsematemesis. 

862. The sputa are sometimes submitted to microscopical examina- 
tion. When they are of such consistence as to allow of it, they should 
be washed lightly in water, as extraneous matters from the mouth are 
apt to cling to them. Small portions of the 

mass may then be covered by thin glass and Fig. 48. 

examined. In this way we may recognise the 
fibres of the elastic tissue of the air-cells (Fig. 
48), indicating a destruction of the substance 
of the lung, as in phthisis and gangrene ; casts 
of the minute air-tubes, as in pneumonia and 
bronchial polypus ; and the small granular 
matter of tubeicle in phthisis. The sputa in 
this disease are frequently found to be made up 
of semi-ti ansparent round, oval, or triangular 
spots, consisting of small granular cells {tu- 
bercle corpuscles) , mixed with free granules 

and oil- globules. Sometimes, also, they contain fragments of mixed phos- 
phate and carbonate of lime, w r hich effervesce on the addition of an acid. 




200 SYMPTOMS AND SIGNS OF DISEASE. 

863. (4.) The Urinary and Genital Organs. — The urine itself 
has been minutely examined in a previous section of this chapter. The 
indications afforded by the mode of passing the urine remain to be con- 
sidered. It may be voided with difficulty (dysuria), and the difficulty 
may be attended by acute suffering at the neck of the bladder (stran- 
gury). The slighter degrees of dysuria are sometimes caused by 
pressure, or by irritation, propagated from a neighbouring organ, the 
rectum, when loaded with faeces, or worms — causes of dysuria readily 
removed by a brisk aperient. Enlargement of the womb, as in ad- 
vanced pregnancy, or irritation of the vagina, as in acute gononhoea, may 
cause the same symptoms in the female. Inflammatory affections of 
the rectum, such as dysentery, will also occasion it; and the irritant 
poisons cause it, partly by the inflammation set up in the rectum, partly 
by the irritating quality imparted to the urine. Two poisons especi- 
ally, cantharides and turpentine, possess the property of inflaming the 
whole urinary system, and exciting strangury, with painful erections 
of the penis in the male, and excitement of the genital organs in the 
female. Frequent and painful micturition may also be occasioned by a 
highly acid state of the urine, by gravel, and by the poison of scarlatina 
when in course of elimination by the kidneys. Affections of the bladder 
itself, such as inflammation (the offspring sometimes of catarrh, some- 
times of gonorrhoea extending from the urethra), ulceration, spasm, and 
fungous growths, may give rise to the same symptom ; or it may be 
traced to similar affections of the urethra, to stricture, to enlargement of 
the prostate, or to the passage of calculi. 

864. Retention of urine, from an obstacle to the discharge of the 
urine actually secreted, must be distinguished from suppression of 
urine (ischuria), the effect of disease of the kidney arresting the secre- 
tion. Retention of urine may result from continued over-distention of 
the bladder, exhausting the power of the muscular coat ; or from disease 
of the spinal cord paralysing it; or from loss of sensibility through 
cerebral disease, or extreme functional disorder of the nervous centres, 
as in continued fever and in typhous states of the system. Spasm of the 
neck of the bladder is another cause of retention, it bears its part in 
that caused by want of opportunity to void the urine ; and it sometimes 
occurs in hysterical females. In many cases the cause of retention is 
mechanical. The seat of the obstruction may be in the ureter (as in 
the passage of a calculus from the kidney), or in the canal of the urethra 
from the same cause, from enlargement of the middle lobe of the prostate, 
or from the pressure of a tumour external to the canal. 

865. Suppression of urine (Ischuria renalis) means a cessation of the 
secretion of the kidneys. This may occur in consequence of idiopathic 
inflammation of the kidney, or of inflammation produced by irritant 
poisons, especially cantharides and corrosive sublimate. It may also 
occur after scarlet fever ; and it is a symptom of Asiatic cholera. Con- 
gestion of the kidney, without inflammation, may also occasion it. The 
effect of prolonged suppression is great drowsiness, passing gradually 
into coma. 



pain. 201 

866. The sexual organs of the male occasionally furnish useful indi- 
cations. A troublesome irritation of the glans penis and prepuce, with 
frequent erections (priapism), characterises stone in the bladder. Erec- 
tions, without irritation of the extremity of the organ, also occur from 
congestion of the kidney, from irritation at the neck of the bladder, and 
from inflammation of the canal of the urethra. Painful erections, with 
curvature of the organ, constitute the most troublesome symptom of 
gonorrhoea. Priapism is also a leading symptom of poisoning by cantha- 
rides and turpentine, and of other active poisons of the irritant class, 
Erection of the penis, with discharge of urine or other fluid, and expul- 
sion of faeces, is also a not uncommon occurrence in death by hanging and 
decapitation ; in poisoning by prussic acid ; in the epileptic fit ; and in 
other forms of violent and sudden death. 

867. The sexual organs of the female are subject to many diseases, 
some of which deserve notice as symptoms or concomitants of other 
diseases or disorders of the system. Anaemia, for instance, is often ac- 
companied by amenorrhcea, as is the opposite state of plethora, though 
less frequently. Certain mental disorders, again, especially some forms 
of instinctive mania, and some varieties of monomania, are found asso- 
ciated with amenorrhcea, dysmenorrhea, or the change of life. The 
importance attached to the menstrual function by patients, and the 
occasional association of disorders of menstruation with constitutional 
disturbance, and especially with hysteria, render it expedient for the 
medical man to inquire into the state of this function in all cases that 
come under his care. The suppression of the menstrual discharge, the en- 
largement of the breasts, with the darkened and otherwise altered ap- 
pearance of the areola, the change in the shape and size of the abdomen, 
and certain changes in the uterus itself, have great importance as signs 
of pregnancy. 

868. (5.) The Nervous System. — The symptoms and signs of 
disease which have to be treated under this head consist of a, altered sen- 
sation ; 6, altered muscular action ; and c, altered mental phenomena. 

869. (a.) Altered Sensation. — All the organs of sense may suffer in 
three ways : the sensation of which they are the seat may be blunted or 
lost, heightened or perverted. The muscles also, and those viscera which 
are not organs of sense, and in health perform their functions uncon- 
sciously, may become, through disease, highly sensitive, and the seats 
of acute pain. Again, all parts of the body, whether endowed with 
sensibility or not, may manifest pain on pressure, or forcible extension. 

870. Pain. — In estimating the value of pain as a symptom of disease, 
we have to consider its degree, its character, its seat, its extent, its dura- 
tion, its persistence or otherwise, and its concomitants. In estimating 
the degree of pain, it is necessary to bear in mind the difference of ex- 
pression used by patients in describing it, according as they have more 
or less general sensibility, more or less fortitude, and more or less honesty. 
The lesser degrees of pain are usually spoken of as slight, moderate, bear- 
able ; the greater degrees as acute, intense, severe, violent, excruciating, 



202 SYMPTOMS AOT SIGNS OF DISEASE. 

agonising, distracting, intolerable. The only general principle of practi- 
cal importance which can be laid down in respect of degrees of pain is, 
that the most acute pain is often occasioned by causes that entail the 
least danger to life ; while the lesser degrees of pain are often present 
in diseases of far more formidable character. It should also be borne 
in mind that there are states of system, such as hysteria, which exagge- 
rate pain, and others, such as lethargy and the typhous state, which 
tend to conceal it. 

871. The character, like the degree, of pain is subject to considerable 
variety, and assists us in tracing it to its source and assigning its true 
cause. A dull, obtuse, aching pain is common in congestions and sub- 
acute inflammations, and even in acute inflammations of soft and yield- 
ing parts. There is a dull, aching pain in the right side in congestion of 
the liver, in the loins in congestion of the kidney, and in the head, back, 
and limbs, at the onset of severe febrile attacks. A higher degree of the 
dull, aching pain is present in periostitis, rheumatism, gout, and the 
milder forms of neuralgia, when it is distinguished as a gnawing pain. 
A burning pain is often present in severe inflammations, as a combined 
result of heat and tension. A throbbing pain is present in inflamed 
parts subject to pressure, as in the common whitloe, and also in all 
abscesses similarly circumstanced. Pain in parts of the intestinal canal 
is commonly described as griping or twisting. In scirrhous tumours, 
and in neuralgia, the pain is designated as shooting, cutting, darting, 
lancinating. 

872. The seat of pain may afford useful indications by corresponding 
with the diseased part or organ which occasions it, or by the part affected 
with pain being in connection with the immediate seat of the disease by 
the intervention of nerves more or less directly traceable from the one 
to the other, Thus, disease of the hip-joint occasions pain in the knee ; 
stone in the bladder, pain in the glans penis (in the female, pain at the 
meatus urinarius) ; inflammation of the kidney, and calculus in the 
ureter, cause pain in the groin, thigh, and testicle ; disease of the womb, 
pain in the loins ; constipation, pain down the back of the thigh ; in- 
flammation of the liver, pain in the right shoulder ; and disease of the 
heart, pain in the left arm, or down to the bend of both arms. Leucor- 
rhoeal discharges, and all causes of debility in nervous and irritable 
females, give rise to pain in the left side ; a tender state of the spinal 
cord, to superficial thoracic and abdominal pains ; and irritation at the 
root of a sensitive nerve to pain in all the parts to which its branches 
are distributed. Some of these pains are called sympathetic. 

873. Of the extent of pain it may be said (as a general rule) that 
pain limited to one spot is more likely to indicate severe disease than 
pain of greater extent. The pains of muscular rheumatism are generally 
extensive, as are those which attack hysteric females. But, on the other 
hand, neuralgic pains are often limited to small spots, as the brow, or 
to single organs, as the testicle or mamma. 

874. The duration of pain is a point of importance, especially when 



THE SENSES OF SIGHT AND TOUCH. 203 

taken in connection with the general health. Pain of long continuance, 
not materially affecting the health, would probably be neuralgic; and 
in the female would be likely to be connected with other symptoms of 
hysteria. The persistence, or otherwise, of pain is also well worth at- 
tention. As a general rule, the pain in important local diseases is con- 
tinuous, though liable to exacerbations, and, under the use of medicines, 
to abatement. In less important cases pains are fugitive, wandering, 
shifting. In one disease — brow-ague — the pain is intermittent, or re- 
mittent. 

875. The concomitants of pain are also highly important. As a 
general rule, the pain of inflammation is increased by pressure, and mus- 
cular pain by motion of the part, or by brisk percussion with the points 
of the fingers, while neuralgic pains are independent of the^e causes, and 
the pains of colic are relieved by pressure. As a general rule, neuralgic, 
rheumatic, and gouty pains are compatible with health, or with only 
slight departures from it, while most other pains are associated with 
marked deviations from it. 

876. Diminished Sensation. — All the organs of sense may be the seat 
of sensibility blunted or lost : and as this condition sometimes furnishes 
important indications, it will have to be considered as it affects the 
senses of touch, sight, hearing, smell, and taste. 

877. The sense of touch may be so impaired as to give rise to the 
sensation of numbness, which may be brought about by cold, by pres- 
sure on the trunks of the nerves, or by the local action of narcotic poisons. 
Long-continued numbness would probably arise from pressure on the 
trunk of a nerve, or of some disease of the nerve itself, impairing but 
not destroying its function. Total loss of sensation in any part of the 
body would follow stronger pressure, or severe disease of the nerve or 
nervous centres. Loss of sensation in the upper or lower extremities, 
or in the whole body, is an occasional accompaniment of muscular pa- 
ralysis of the same parts. A loss of sensibility is occasionally present 
in hysteric females, and may be brought about by narcotics and by mes- 
meric manipulations. In examining patients with a view to determine 
the presence or absence of sensibility, it should he borne in mind that 
strong muscular contractions may follow irritation of the skin from re- 
flex action, in the absence of sensation. 

878. The sense of sight is variously affected, not merely from local 
causes attacking the organ itself, but also from disordered and diseased 
conditions of brain. Slight and transient affections of the sight are 
common in dyspepsia, and in slight febrile and other disturbances of the 
circulation. These affections consist in dark spots (muscae volitantes), 
bright spots, sparks, or brilliant colours (as seen by persons drowning 
or hanging), or in simple indistinctness of vision, in a flickering motion, 
in a double vision, as in the drunkard, or in a half vision of objects. 
Spectral illusions have already been considered at p. 109. A heightened 
sensibility of the retina, accompanied by a dread of light (photophobia), 



204 SYMPTOMS AND SIGNS OF DISEASE. 

is a common symptom of acute inflammations of the eve itself, and of 
inflammatory affections of the brain. It may also be present in acute 
ana-mia from loss of blood, and in the hysteria of weak and delicate fe- 
males. The opposite state of permanently diminished sensibility of the 
retina is usually connected with disease of the optic nerve, or of that 
part of the base of the brain from which the nerve arises. Transient 
dimness of vision, or actual blindness, sometimes occurs from loss of 
blood, from excessive lactation, or from other exhausting discharges, and 
it commonly precedes the fainting state. 

879. Squinting, when not permanent, is often due to affections of the 
brain, and is to be regarded as an unfavourable symptom. It is com- 
mon in children as a consequence of disease of the brain attended by con- 
vulsions ; and the permanent squint of the adult is often the result of 
an affection of the brain in infancy or childhood. 

880. The state of the pupil is a symptom of considerable importance. 
As a general rule it is contracted in irritation of the brain, whether due 
to inflammation of the organ or to other causes, and it is also subject to 
extreme contraction in poisoning by opium and the Calabar bean. On 
the other hand the pupil is apt to be dilated in congestion of the brain 
without irritation, in hydrocephalus, in epilepsy, in some cases and stages 
of apoplexy, and in functional disorders due to remote causes, such as 
constipation and intestinal worms. It is also dilated in poisoning by 
belladonna, hyoscyamus, and stramonium, and by some other poisons be- 
longing to the class of narcotico-acrids, as well as by the local applica- 
tion of the more active members of this class. The condition of the 
pupil is also an indication of the state of the retina. If it contracts 
fieely under the stimulus of light, the retina has not lost its sensibility ; 
if not, there is a loss of sensibility in the nerve, and, in certain cases, in 
the entire nervous system. When, in the absence of disease of the eye 
itself, the pupil of one eye is dilated while that of the other is contracted, 
cerebral disease may be presumed to be present. The state of the sur- 
face of the eye is used as a test of the state of the nervous system. If 
insensible to the touch, the nervous system generally may be assumed to 
be in the same state, Thus it is insensible under the full influence of 
chloroform, and in true epilepsy, but in the feigned disease responds to 
the touch. 

881. The sense of hearing is subject to analogous affections with the 
sense of sight — to ringing sounds (tinnitus aurium), to distinct musical 
notes, and to puffing sounds like the noise of a locomotive. These may 
occur from slight and transient causes, and need not excite apprehension. 
But they may also usher in chronic or acute diseases of the brain. Of 
more marked illusions of the sense of hearing, something has been said 
at p. 109. The sense of hearing is generally acutely painful in inflam- 
matory affections of the brain ; and, in common with the sight, in the 
opposite state of the cerebral circulation ; also in some cases of hysteria. 
Deafness is a common occurrence, and often a favourable sign, in febrile 
diseases, and in the febrile exanthemata. In some instances it is asso- 






CONVULSIONS AND SPASMS. 205 

dated with cerebral disease, and forms one of the group of symptoms by 
which it may be recognised. 

882. The sense of smell is subject to illusions similar to those that 
affect the eye and ear ; but the disorders of this sense have little signi- 
ficance as signs of disease. 

The sense of taste has been already considered in § 842. 

883. (6.) Altered Muscular Action. — The muscles are subject to para- 
lysis, to convulsion, and to spasm. Paralysis may be local or general, 
of greater or less extent. It may affect the muscles of the tongue, or 
the muscles of the upper eyelid (causing ptosis), or several of the muscles 
of the eyeball (causing strabismus), or the muscles supplied by the 
facial nerve (causing palsy of one side of the face), or the muscles of one 
arm or one leg, or the muscles of one side of the body (hemiplegia), or 
the muscles of the lower half of the body (paraplegia). The loss of 
power may also vary in degree, being complete or incomplete. The 
cause of local paralysis may be either pressure in the course of the nerve 
supplying the palsied part, or disease of the spinal cord. As a general 
rule, paraplegia may be traced to injury or disease of the spinal cord, 
and hemiplegia to disease of one hemisphere of the brain. A local and 
limited palsy, traced to a nerve issuing from the base of the skull, becomes 
an important indication of cerebral disease, if accompanied by palsy of 
some part supplied by a nerve issuing from another foramen. 

; 884. Convulsive muscular actions often afford important indications. 
Some distinctions worth bearing in mind are referred to at § 456. The 
convulsive actions most important to observe at the bedside are the 
twitchings of the muscles in low febrile attacks (subsultus tendinum), 
the picking at the bedclothes known as floccitatio, and the tremulous 
protrusion of the tongue. These symptoms only occur in cases which 
combine great weakness with much excitement of the nervous system ; 
and they are highly unfavourable, though not fatal, symptoms. Con- 
vulsions are also common in infancy and childhood, and may be brought 
on by the irritation of teething, constipation, or worms. They are also 
present, sometimes as an early symptom, in hydrocephalus. In young 
persons they show themselves in the form of chorea or epilepsy ; in adults 
in epileptic and hysteric seizures, in delirium tremens, uraeinia, and in 
many kinds of poisoning. They may aI>o occur on one side of the body, 
while the other is palsied. In sudden death fiom great violence, or 
from large doses of such active poisons as p.ussic acid, general convul- 
sions, attended, as in epileptic fits, by expulsion of urine and fseces, pre- 
cede death. 

885. Spasmodic actions of the muscles, or prolonged and rigid con- 
ti action, occur in tetanus and hydrophobia; and in some forms of hys- 
teria. They constitute the characteristic symptoms of poisoning by 
strychnia, and an occasional symptom of poisoning by some of the more 
active members of all the great classes of poisons. Similar rigid con- 
tractions of single muscles, or of groups of muscles, of long continuance, 



206 SYMPTOMS AND SIGNS OF DISEASE. 

attend organic disease of the brain, and constitute a very formidable 
symptom. Strabismus is one consequence of rigid contraction of a 
single muscle. 

886. (c.) Altered Mental Phenomena. — These have been already 
treated of in a former chapter (p. 116) ; it only remains in this place 
to speak of that condition known as coma. Coma is a state of complete 
insensibility and loss of motive power. It may arise from several causes : 
from apoplexy ; from such poisons as opium and carbonic acid gas ; 
from drunkenness ; from the operation of intense cold ; from poisoning 
of the blood, as in uraemia; and from accumulation of serum in or on 
the brain. In distinguishing the coma of drunkenness from that of 
apoplexy we are assisted by the odour of the breath. 

887. The Temperature of the Body. — This subject has re- 
cently attracted much attention both abroad and at home; and the in- 
vestigations of WunderHch, Parkes, and Ringer, confirmed by others, 
show that the use of the thermometer from day to day may furnish use- 
ful indications, both by coinciding with, and by somewhat anticipating, 
changes in the circulation as indicated by the pulse. Some observations 
on the high temperature attained in some febrile disorders will be found 
at p. 101. 

888. (7.) The Expression of the Countenance, and the 
Condition and Attitude of the Body. — The expression and as- 
pect of the countenance often afford great assistance in diagnosis, but it 
is not easy to convey a just idea of the physiognomy of disease by verbal 
description. The varieties of mental disease are strongly marked on the 
countenance. The wild excitement of mania, the deep despondency of 
melancholia, the vacant look of the idiot, imbecile, and demented, are 
familiar to all observers. Patients suffering from delirium tremens have 
often an air of extreme suspicion, and the habitual epileptic comes to wear 
a peculiar expiession. ^gain, phthisis, emphysema, organic disease of 
the heart, diabetes, and Bright's disease, betray themselves to the ex- 
perienced physician by the expression of the countenance : and hys- 
teria is often detected by rapid transitions fiom tears to smiles, and by 
an appearance of health in bad keeping with the complaints of the patient. 

889. The condition of the body in respect of nutrition and colour, 
and dryness or moistness of skin, always claim the attention of the 
physician. Rapid loss of flesh, or sudden corpulency, should equally ex- 
cite attention. The one is common in such maladies as pulmonary con- 
sumption, diabetes, and organic disease of the stomach, as well as in 
diseases attended by profuse discharges ; also in the decay of aged per- 
sons ; the other may follow recovery from pulmonary consumption, or 
precede attacks of apoplexy. But corpulency in healthy persons may 
be due to a transition from active to indolent habits. 

890. The posture of the body is often highly characteristic. It be- 
trays loss of power in the paralytic, and weakness in the exhausted. The 
last stage of fever and of all exhausting maladies is marked by the help- 



HYGIENE. 207 

less attitude on the back ; and the assumption of a position on the sides, 
such as is common in sleep, often affords an early and most welcome 
sign of commencing recovery from fever. The sitting or semi -recum- 
bent posture, with the head raised by pillows, is highly characteristic of 
diseases directly or indirectly affecting the breathing, such as severe 
diseases of the lungs, and advanced diseases of the heart. The recum- 
bent posture, with the legs drawn up, is equally characteristic of painful 
diseases of the abdominal viscera. In diseases of the chest we should 
note on which side the patient lies with most ease and comfort. As a 
general rule he lies on the diseased side of the chest ; but the choice of 
position being determined in one case by a sense of pressuie, in another 
by a sense of dragging, in a third by the ease with which the fluids gra- 
vitate to the air-tubes, and in many cases by several conditions com- 
bined, the inferences to be drawn from posture are less satisfactory than 
could be wished. In painful diseases of the abdominal viscera, the 
patient, as a general rule, lies easiest on the side of the disease. 



CHAPTEK V. 

HYGIENE. 



891. In a large proportion of the cases that come under the care of 
the physician, both in private practice and among the poor, it is neces- 
sary to pay some attention to those circumstances which affect the general 
health of the patient, and to lay down rules for his guidance in matters 
that belong rather to the province of Hygiene than to the Practice of 
Physic. Indeed it often happens that the only remedial measures w T hich 
the physician feels called on to prescribe consist of a change from bad 
to good habits of life, from an unhealthy residence or locality to a healthy 
one, from intense application to study or business to repose of mind and 
complete change of scene and occupation. In a certain class of cases, 
again, change of climate is the appropriate remedy, and the physician 
has to choose a locality suited to the disease or state of health of the 
patient. 

With this regulation of the habits and residence of their patients, the 
hygienic duties of the greater number of medical men terminate; but 
there are duties of a larger and more comprehensive character in the 
right performance of which many medical men are directly interested — 
some as officers to such public institutions as workhouses, prisons, schools, 
hospitals, and lunatic asylums ; some as officers in the army and navy, 
in charge of camps, barracks, ships of war, and merchant and emigrant 
vessels ; others, again, as district officers of health. 

The subject of this chapter may, therefore, be properly treated under 
the two distinct heads of private and public hygiene. 



208 HYGIENE. 

1. PRIVATE HYGIENE. 

892. The principal matters which require to be regulated, with a 
view either to the preservation of health in the strong, or its restora- 
tion in the invalid, are diet, exercise, clothing, condition of dwelling, 
place of residence, and habits of life. Diet, as appropriate to persons of 
different ages, and as applicable to particular maladies and states of 
system, will be treated in the next chapter. 

893. Exercise, regulated according to the state of the patient, is a 
very important therapeutic agent. It may be of two kinds — active 
and pass ice : in the one the patient moves about by the exertion of his 
own muscles; in the other he is borne from place to place. Walking, 
running, dancing, riding, rowing, fencing, boxing, wrestling, drilling, 
and all gymnastic exercises and active games, belong to the first class ; 
riding at foot-pace, carriage exercise, sailing, rocking, and swinging, to 
the second. 

894. Both kinds of exercise call the muscles into play, and promote 
the circulation of the blood ; but in the passive foim the muscles are 
only employed in maintaining the posture, while the circulation is 
quickened only by slight displacements of blood. 

895. Besides the advantage of quickening the circulation, active exer- 
cises, by calling the abdominal muscles into play, promote the action of 
the bowels. Those exercises, too, whether active or passive, which are 
carried on in the open air, have the incidental advantage of supplying 
a purer air for respiration ; and they imply a change of scene and occu- 
pation, which reacts favourably on the mind. 

896. In prescribing the kind and amount of exercise the physician 
must be guided by the circumstances of each particular case. In the 
absence of organic disease, and when the patient suffers merely from 
general debility brought on by overwork, intense study, or too close at- 
tention to business, the choice of an appropriate exercise must be mainly 
determined by his circumstances and tastes. If practicable, change of air 
and scene, with the exercise which travelling implies, should be in- 
sisted on ; and, where the strength allows of it, pedestrian exercise. A 
sea voyage is in these cases to be preferred to carriage exercise. When 
the patient is unable to quit the scene of his studies or business, horse 
exercise in the morning or evening of the day will be found most suit- 
able ; and this is especially the case with the inhabitants of large cities 
who cannot readily reach the country on foot. Fencing, rowing, quoit- 
playing, archery, and cricket have the double advantage of bringing all 
the mu.-cles of the body into play, and of' compressing a great amount 
of exercise into a small compass of time. Archery deserves encourage- 
ment as an exercise suited to persons of either sex. 

897. For growing children of delicate health, exercise is of the utmost 
importance, and the active games of childhood may be combined with 
equestrian exercise and instruction in the graceful accomplishments of 






CLOTHING. 209 

dancing and fencing. In these cases much anxiety is often felt respect- 
ing the development of the chest, especially where a tendency to con- 
sumption is supposed to exist. With a view to promote this object, 
drilling, and the manly exercise of fencing may be strongly recommended 
for young men, and the nearest convenient approach to it for young 
women. It is greatly to be preferred to dumb-bells, to the clubs, or to 
other gymnastic exercises which consist of tedious repetitions of the same 
movements. Heading aloud, strongly recommended by ancient medical 
authorities, might be revived with great advantage ; but in order to 
guard against the formation of habits injurious to the free play of the 
lungs, a judicious teacher should be engaged. Singing, properly taught, 
has the same recommendation. 

898. In organic disease of the lungs or heart, all the stronger exer- 
cises, whether active or passive, are inadmissible, and walking on level 
ground is. in such case, the strongest exercise that can be safely pre- 
scribed. It is greatly to be preferred to almost any form of passive 
exercise except that of the carriage or garden chair. Running, or even 
walking at a brisk pace, and all athletic sports, are inadmissible. The 
more violent exercises, especially rowing in races, have often given rise 
to these diseases in persons having every appearance of strength and 
vigour. Gymnastic exercises, requiring prolonged and violent action ot 
the muscles, are open to the same objection. 

899. On the subject of clothing much misapprehension exists. There 
is a strong tendency towards over-clothing of the body, and especially of 
the chest, with a view of guarding against pulmonary disorders. A 
delicate patient is often made to wear, in the very height of summer, as 
many flannels and skins as would guarantee the temperature of the body 
in a polar winter, and in this way the very risk of catching cold, which 
it is deemed so important to avoid, is incurred. The same error is 
committed when, in addition to a load of bed-clothes, much exceeding 
what is required to preserve the proper temperature of the body, flannel 
is worn next the skin at night. 

900. An opposite error is sometimes committed in very young 
children, under the erroneous notion of hardening them. At the other 
extreme of life warm clothing is highly necessary, especially in patients 
suffering from pulmonary affections ; and great care should be taken in 
severe weather to keep up the temperature of the sleeping apartment 
throughout the night. 

901. Young men who persist in wearing no other covering to the 
chest throughout the year but the linen shirt, and refuse to wear cotton 
or flannel next the skin in winter, are also in error. A thin cotton vest 
next the skin should be worn even in summer, especially by those who 
perspire freely. In hot climates cotton, in cold climates flannel, is the 
proper material for body-clothing. The importance of an immediate 
change after active exercise, or when the clothes are wet, need not be 
insisted on. 

P 



210 PRIVATE HYGIENE. 

902. The condition of Ms dwelling is of great importance to the in- 
valid. The points to be attended to in choosing a house, or in planning 
a residence, are chiefly the following : — 

Site and Soil. — Where there is a free choice, a gravelly or chalky soil 
and sloping ground are to be preferred to a clay soil and low level site. 
A tenacious clay soil, a rich alluvium, or a dry surface soil with water 
at a short distance beneath, should be avoided, but especially the flat 
banks of rivers or streams, or the flat base of hills, as well as marshy spots, 
and the neighbourhood of stagnant water. The worst combination 
of site and soil is a flat alluvial deposit receiving the drainage of sloping 
grounds. Such spots are favourite haunts of continued fevers, as 
marshes are of agues ; and good ground has been lately assigned for 
tracing many cases of consumption to the same cause. 

Aspect. — In England a south aspect is to be preferred as being free 
from the extremes of heat and cold ; and it is well suited to the invalid. 
A north aspect lacks both light and warmth. An east aspect has the 
advantage of the light and warmth of the morning sun, but is exposed 
to the cold drying winds of winter. A west aspect is open to the objec- 
tion of being too hot in the after part of the day. In houses which can 
have only two opposite aspects, a south-east and a north- west are to be 
preferred. When there is perfect freedom of choice, a morning room to 
the east, the principal sitting-room to the south, wuth bed-rooms to the 
south for invalids and aged persons, and to the east for young and 
healthy ones, is a desirable combination. Dairies, larders, and store- 
rooms should be to the north. 

Shelter. — Houses require shelter from the north and east ; and when 
such shelter is not afforded by nature, it should be secured by planta- 
tions, which ought in no case be so near the house as to obstruct the 
free movement of air, or to endanger its foundations by the growth of 
roots. To the south and west the house should be open ; but large 
trees at a moderate distance on the west side, afford a grateful shade 
from the heat in summer. 

Water-supply. — A well, yielding clear, colourless water, and a tank 
to hold a supply of rain-water from the roof, amounting to at least ten 
gallons per head per diem for a month or six weeks, are great desiderata. 

Drainage. — The soil on which the house stands should be thoroughly 
drained, and all offensive refuse promptly removed by impervious pipes 
properly trapped. Water-closets should be so placed that the drains mav 
not pass under the house. In erecting places of convenience out-of- 
doors, the spots chosen should not be too near the dwelling, and the 
barbarous custom of digging deep cesspools should be avoided, especially 
in light soils, and near w T ells and springs. The proper construction is 
that adopted in many northern towns. A piece of ground should be 
rendered impervious to moisture by ramming or paving ; on this the 
offensive matters and the slops from the house should be received, and 
the dust with the sifted ashes from the fires should be thrown upon 
them, through a hopper in the side. At short intervals of a fortnight, 



VENTILATION AND WAEMING. 211 

or month, the accumulated matters should be removed and thrown upon 
a compost-heap. These simple arrangements have the advantage of 
being both wholesome and economical. W the dust and ashes of the hou<e 
prove insufficient, dry earth may be added ; or the arrangement now 
known as the ' earth-closet ' may be adopted from the first. 

The preservation of dwellings from dampness is of the first import- 
ance. To accomplish this it is not sufficient to make the roof proof 
against the weather; the basement also must be attended to. The floor 
or pavement should be raised on dwarf-walls, supplied with air-bricks, 
and the house should be surrounded by an area or air-drain, so that the 
walls may be kept from contact with the soil. These precautions are 
especially necessary in clay and rich alluvial soils, difficult of drainage. 

Light and Air. — Rooms should be lofty and spacious, and have open 
fire-places, and windows opening above and below. Staircases well lighted 
and aired by windows opening upon them, are to be preferred to those 
lighted by sky-lights, even when the lights admit of being opened. Pure 
air, especially in the bedroom of the invalid, should be guaranteed by 
the open fire-place. When the rooms are spacious, no special provision 
for ventilation is required beyond the facility of opening doors and 
windows. But small sleeping rooms require a constant provision for 
the renewal of the air by means of ventilators so constructed as to 
prevent drafts. 

903. In order to preserve the health of delicate children, it is essen- 
tial to provide for the free ventilation of their sleeping apartments. 
Overcrowding and consequent impurity of the air in such apartments is 
a common cause of disease in the children even of affluent persons, and 
a principal source of the high mortality of the children of the poor. In 
addition to the precautions for insuring thorough ventilation, a certain 
amount of space, approaching the thousand cubic feet insisted on in 
§ 221, should be allotted to each child. 

904. In cities, and even in rural districts, the external air admitted 
into the houses both of rich and poor is often very far from being sweet 
and pure. In the country the causes of impurity are few in number, 
being chiefly the gases from stagnant pools, ponds, or marshes, or the 
effluvia from cesspools, farm-yards, stables, pig-sties, or heaps of manure. 
These sources of impurity should always be placed at a distance from 
dwelling-houses ; and in no case should they be in contact with them. 

905. In large cities the sources of aerial impurity are much more 
numerous, and become doubly objectionable from narrow space and im- 
perfect movement of the air. They consist in emanations from manufac- 
tures peculiar to towns, from the necessity of heaping up, at least for a 
short time, the dust and ashes of our houses, from the difficulty of con- 
suming the smoke of our chimneys, and from the defects inherent in a 
large and complicated system of sewerage. 

906. Warming. — This should be so effected as not to interfere with 
ventilation. Close stoves should, therefore, be banished from living or 



212 PRIVATE HYGIEXE. 

sleeping apartments ; their use being; restricted to entrance halls, stair- 
cases, and large rooms only occasionally occupied. For living and sleep- 
ing rooms the best combination is an open fireplace of sufficient size and 
good radiating surface, with double windows, double panes of glass, or 
thick plate glass. In this way (especially when the walls of the house 
are thick, or double) any temperature that may be desired can be com- 
bined with complete ventilation. This mode of insuring a supply of 
warm pure air is of great importance in pulmonary diseases, especially 
in the bronchitis of aged persons. 

907. Among the habits of life which militate most against health, 
and tend to counteract the best medical treatment, the chief are sloth, 
luxury, dissipation, indulgence in the pleasures of the table, the abuse of 
spirituous liquors, opium, and tobacco, irregularity in the time of taking 
meals and rest, and want of personal cleanliness. 

908. For those whose constitutions have been undermined by sloth, 
luxury, and dissipation (Chap. I. § 84), travelling, and the wholesome 
observances of fashionable watering-places — early rising, regular hours 
for meals and exercise, the frequent use of baths, and cheerful and con- 
genial society — are the only remedies which we have it in our power to 
prescribe. As intemperance and indulgence in the pleasures of the table 
are the besetting temptations of the same persons, there is perhaps no 
better way of guarding against them than by prescribing foreign travel, 
or a residence at fashionable watering-places. 

909. When the abuse of spirituous liquors, opium, or tobacco is re- 
cognised as a cause of disease, steps should be taken to abolish these 
practices slowly and gradually, both on account of the greater safety 
of this procedure, and of the greater ease with which the patient may 
thus be made to lay his bad habits aside. 

910. Irregularity in the time of taking meals and rest is an evil in- 
cident to the busy life of large cities, and one which we are often called 
upon to remedy by prescribing such improved habits as are compatible 
with the exigencies Gf the patient's business. 

911. A want of personal cleanliness is more frequently chargeable 
against persons of education than might be expected. The practice of 
daily ablution of the whole body is observed by a comparatively small 
number of persons ; but it is one to be commended as an excellent tonic, 
as tending to guard the body against catching cold, and as keeping the 
pores of the skin open. The warm bath should be occasionally employed 
to insure a more perfect cleansing of the skin. The practice of daily 
ablution with cold water, followed by friction with a rough towel, hair 
gloves, or the flesh-brush, is often of the greatest benefit to those who 
have an hereditary predisposition to consumption, or who have already 
manifested a tendency to it. 

912. Change of air or climate is generally esteemed a most im- 
portant means of preserving, improving, and restoring health. There 
are two classes of persons to whom it is usual to recommend the change. 



CHANGE OF CLIMATE. 213 

The one consists of invalids who suffer from no denned disease, but 
whose general health has been impaired by exposure to one or other of 
the many unwholesome influences which attend a residence in large towns 
(see § 71 et seq.) ; the other comprises persons suffering from some 
well-defined malady, such as chronic dyspepsia, chronic rheumatism, 
scrofula, pulmonary consumption, chronic bronchitis, and asthma. 

913. To the mere invalid, who has suffered by the cares and anxieties 
of business, the dissipation of a town life, or the ennui of an idle and 
useless existence, change of climate is chiefly valuable as affording faci- 
lities for change of habits, scene, and occupation. In advising such per- 
sons, little more is required than to avoid climates positively unhealthy, 
and to make choice of countries or places which offer the greatest faci- 
lities for change of habits and occupation ; and in the case of the victim 
of ennui, the greatest inducements to exertion of mind and body. 

914. In advising patients suffering from actual disease, a more exact 
knowledge of climate is required, at the same time that considerations 
of personal convenience will have to be carefully weighed. Assuming 
that there are no circumstances peculiar to the patient which render a 
change of residence inexpedient, the medical man will have first to con- 
sider the kind of climate best adapted to his disease, and then to select 
from a number of places having the required climate the particular one 
which is, on the whole, to be preferred. 

915. In making choice of a climate, we may either consider the state 
of the patient's system, without reference to his disease, or we may be 
guided solely by the nature of his malady. The state of system may 
be either one of relaxation, characterised, if the disease affect any of the 
mucous membranes, by excessive secretion ; if the glandular system, by 
indolent swellings or ulcers ; if the skin, by chronic cutaneous affections ; 
if the locomotive system, by chronic rheumatism and atonic gout. A 
cold skin, and a weak pulse, perhaps below the natural standard of fre- 
quency, with general languor of all the functions of the body, charac- 
terise this state. On the other hand, the state of system may be one of 
irritation, with a dry state of the mucous membranes, a harsh dry skin, 
and a frequent quick pulse, with a tendency to more acute forms of in- 
flammation. In the state of relaxation, a dry bracing climate is indi- 
cated ; in the state of irritation, a mild moist climate. In both, it is 
important to avoid a great increase of temperature as tending to exhaus- 
tion, sudden changes, as giving rise to cold and slight febrile attacks, and 
the east and north-east winds, as shown by experience to be peculiarly 
trying to the invalid. In chronic rheumatism, gout, and calculous dis- 
orders, a higher temperature appears to be advantageous. The climate 
of the East and West Indies, and of the Cape of Good Hope, is deemed 
suitable to this class of invalids. 

916. As a general rule, the bracing spots adapted to a state of relax- 
ation are those which are elevated, scantily wooded, exposed to the pre- 
vailing winds, and consisting of a gravelly or chalky soil ; on the other 
hand, the mild moist climates are to be found in low situations, on clay 



214 PKIVATE HYGIEXE. 

soils, wooded, and partially or wholly uncultivated, and sheltered from 
the prevailing winds. As a general rule, too, the climate of the sea- 
shore is milder and more uniform than that of the interior, being warmer 
in winter and cooler in summer. Watering-places have also the twofold 
advantages of pure sea-breezes and of sea-bathing. 

917. Bearing these considerations in mind, it will be easy to point 
out, among the common resorts of the invalid, the places in England 
and abroad best adapted to the two opposite states of relaxation and 
irritation. 

918. The mild sheltered places most resorted to on the English coast, 
are Undercliff in the Isle of Wight ; Hastings on the south coast ; Daw* 
lish, Sidmouth, Exmouth, and Salcombe, on the coast of Devon. The 
sheltered spots in the islands of Guernsey and Jersey ; Pau in the south- 
west, and Hyeres and Nice in the south-east of France ; Rome and 
Pisa in Italy ; and Malaga in the south of Spain, offer the like advan- 
tages abroad. The islands of the Northern Atlantic (Madeira, the 
Canaries, and the Azores) and those of the Western Atlantic (the Ber- 
mudas and Bahamas) have the same mild relaxing climate. 

919. On the other hand, the mild bracing spots adapted to a state of 
debility and relaxation without irritation, are, in England, Brighton, 
on the south coast ; Torquay, on the coast of Devonshire ; Clifton, on 
the western coast ; in France, Montpellier ; in Italy, Naples. 

920. The places named in the two preceding sections must be under- 
stood to be intended chiefly for winter residence, the summer being spent 
inland in such places as Malvern, Cheltenham, Leamington, Tunbridge 
Wells, Matlock, and Buxton, in England; among the higher Pyrenees 
in France ; or at the better situated spas of Germany. 

921. The climate best adapted for residence during the entire year is 
perhaps that of Madeira, which to moderate fluctuations of a tempera- 
ture little exceeding that of the milder parts of England, adds the 
advantage of a drier atmosphere, except during the autumnal rains. 

922. The diseases in which change of climate may be expected to be 
most beneficial are emphysema, chronic bronchitis, asthma, and all those 
affections of the air-passages and lungs in which previous experience has 
shown that the patient suffers severely in winter and is comparatively 
well in summer. The efficacy of change of climate in pulmonary con- 
sumption is not so well established : but in the state known as tuber- 
cular cachexia (the presumed forerunner of tubercular deposit) as in 
other forms of cachexia, change of climate is advantageous. Whether 
a mild bracing or a mild relaxing climate is to be chosen must depend 
on the state of the system, whether it be one of languor and torpid 
action, or one of feverish excitement. (Consult, on this subject of Cli- 
mate, Sir James Clark's able treatise.) 

923. There are certain states of system in which it is expedient to 
combine with change of climate the alterative effects of minute doses of 



MINERAL WATERS. 215 

saline or other substances in a state of solution ; in other words, to select 
as the scene of the required change of climate, regimen, and occupation, 
some spot where access can be had to mineral waters. Such places 
abound both in England and on the Continent. 

924. The mineral waters most in repute may be divided into four 
classes — the saline, chalybeate, sulphureous, and acidulous — to which 
may be added the hot springs. A short description of each of these 
classes, with the principal watering-places where they are found, will 
assist the physician in his choice. 

(1.) Saline Mineral Waters. — These consist of variable quantities ot 
the chlorides, sulphates, carbonates, and nitrates of potash, soda, lime, 
magnesia, and alumina, to which may be added, as of rare occurrence, 
free carbonic or sulphuretted hydrogen gas, the salts of iron in small 
quantity, with traces of phosphoric acid, iodine, and bromine. Sea- 
water is a concentrated form of this class of mineral waters. These 
waters act as gentle aperients, and are adapted to the case of patients 
suffering from dyspepsia, from habitual constipation, and from func- 
tional derangement of the liver. The waters of Cheltenham, Leaming- 
ton, and Scarborough, in England; of Spital-on-Tweed, Pitkaithly, Air- 
threy, Dunblane, and Innerleithen, in Scotland ; and of Ems, Carlsbad, 
Homburg, Seidschutz, Kreuznach, and Piilna, in Germany, belong to 
this class. Some of these mineral waters contain minute quantities of 
iodine and bromine, and, for that reason, commend themselves in scro- 
fulous disorders, accompanied by glandular enlargements. The waters 
of Kissengen and Kreuznach contain the bromide of sodium in sufficient 
quantity (a third and a fourth of a grain in a pound of water) to have 
some effect if taken freely and continuously. The strongest waters be- 
longing to this class are, in England, those of Cheltenham and Leaming- 
ton; in Scotland, those of Airthrey; in Germany, those of Piilna, 
Seidschutz, Homburg, Kreuznach, Kissengen, and Marienbad. 

(2.) Chalybeate Waters. — These contain variable quantities of the 
sulphate and carbonate of iron, and are, therefore, tonics specially adapted 
to the treatment of anaemia, and of functional disorders of the uterus. 
They are slightly stimulating, and require to be combined with aperient 
medicines. The waters of Tunbridge Wells and Harrogate in England, 
of Hartfell Spa and Vicar's Brig in Scotland, of Spa and Tongres in 
Belgium and the Low Countries, of Passy near Paris, and of Rennes in 
the south of France, belong to this class. 

(3.) Sulphureous Waters. — These abound in free sulphuretted hydro- 
gen gas, and are prescribed in several forms of cutaneous disorder. The 
waters of Harrogate in England, of Moffatt, Strathpeffer, and Rothsay 
in Scotland, of Enghien near Paris, of Bareges in the higher Pyrenees, 
of Aix and Leuk in Switzerland, and of Aix-la-Chapelle in Prussia, belong- 
to this class. 

(4.) Acidulous Waters. — These are characterised by the quantity of 
free carbonic acid they contain. They are more or less rich in saline 
ingredients ; so that they might be placed with almost equal propriety 
with those enumerated in Class 1. The excess of free carbonic acid con- 



216 PUBLIC HYGIENE. 

stitutes their claim to a place by themselves. They are applicable in 
the same cases in which saline waters are found useful, but. being more 
stimulant, they are better adapted to cases characterised by great debility. 
The chief mineral waters belonging to this class are those of Ilkeston in 
Derbyshire, of Kissengen, Marienbad, Auschowitz, Eger, Pyimont, Spa, 
Fachingen, Geilnau, Seltzer, and Homburg in Germany; of Pougues, 
Mont d'Or, and Vichy in France ; and the Saratoga Congress Spring in 
America. The waters of Carlsbad and Ems contain comparatively small 
quantities of free carbonic acid. The chief acidulous waters of Germany, 
classed according to the quantity of carbonic acid they contain, beginning 
with the richest, are — Gednau, Pyrmont, Eger, Auschowitz, Spa, Fachin- 
gen, Homburg, and Seltzer. The waters of Homburg take the first 
place among the waters of Germany for combined richness in salts and 
free carbonic acid. 

(5.) Hot Springs. — These are useful both as baths and as internal 
remedies. As baths they have the advantage of containing, like sea- 
water, but in smaller quantity, certain saline ingredients, which act as 
stimulants to the surface. Taken internally they have, according to 
their strength, the properties of saline waters. The principal member 
of this class are the waters of Matlock, Bristol, Buxton, and Bath, in 
England ; of Carlsbad, Ems, and Wiesbaden, in Germany ; of Baden in 
Switzerland; of Plombieres and St. Nectaire in France. Some of these 
hot springs contain, in addition to saline substances, free carbonic acid 
and nitrogen. 

925. The constituents of some springs are such as to give them a 
place in more than one class, and to entitle them to compound appella- 
tions, such as saline chalybeates, named from their combining the pro- 
perties of saline and chalybeate springs. At some favourite watering- 
places, both in England and on the continent, several classes of mineral 
waters are to be found. Both Cheltenham and Leamington, for instance, 
have saline, chalybeate, and sulphureous waters; and Harrogate, in 
addition to strong and mild sulphur-waters, has its pure and its saline 
chalybeates. 

926. There is no way in which most of the bad habits already referred 
to (§ 908) can be more effectually broken through than by a residence 
at some of the least frequented of continental watering places. Those 
most frequented are often ill adapted to this end, as they combine the 
luxuries and temptations of large towns with the absence of those natural 
beauties which offer so wholesome an inducement to pedestrian and other 
exercises. 

2. PUBLIC HYGIENE. 

927. The saddest pages in the history of all nations are those which 
treat of the wholesale sacrifice of human life through ignorance or 
neglect of the simplest means of preserving health and averting disease. 
Such sacrifices have occurred in lying-in hospitals from insufficiency of 
space and neglect of ventilation ; in foundling hospitals from the same 
causes, combined with absence of the mother's care and want of the 



FOUNDLING HOSPITALS, SCHOOLS, AND PRISONS. 217 

infant's proper nourishment ; in schools from want of space, neglect of 
cleanliness, and insufficient and improper food ; in workhouses and 
prisons from the same causes, added to idleness, listlessness, and depres- 
sion ; in civil hospitals chiefly through want of space ; in military hospi- 
tals from the same cause, added to the want of proper medical attention 
and nursing, and sometimes of proper food and medicine ; in emigrant 
and transport ships, and men-of-war, from narrow space, foul air, bad 
water, and bad food ; in armies in the field from ill-chosen encampments, 
bad provisions, overcrowding, neglect of cleanliness, and intemperance. 
Convulsions, infantile tetanus, and gangrene of the mouth ; marasmus ; 
puerperal fever ; Asiatic cholera ; jail fever ; typhus, relapsing fever, 
'parish infection,' and ' the sickness of the house;' scurvy; diarrhoea 
and dysentery ; ophthalmia ; malignant ulcer and hospital gangrene — 
have all been traced to such causes ; while all epidemic maladies, small- 
pox, plague, sweating sickness, black death, and cholera, have committed 
their worst ravages among men, women, and children crowded together, 
and wanting one or more of the simple requisites of pure air and water, 
cleanliness, due shelter, efficient drainage, appropriate clothing, and 
wholesome and suitable food. 

928. It is no disparagement to the art of healing to say that more 
lives have been sacrificed to neglect of the simplest means of preserving 
health than can have been saved by the most skilful medical and surgi- 
cal treatment. It is of the first importance, therefore, that the physician 
should understand and be able to recommend with authority the mea- 
sures to be adopted to preserve the health of men, women, and children 
when of necessity congregated in large nruribers. These measures might, 
indeed, be inferred from what has been said in this chapter on diet, 
exercise, clothing, condition of dwelling, place of residence, and habits of 
life, and, in the earlier chapters of this work, on the causes of disease ; 
but the precepts thus laid down for individuals require to be modified 
in order to meet the cases of men, women, and children in the aggregate. 

929. Of foundling hospitals, for the reception of infants, it is not 
necessary to say more than that they are as indefensible on physical as 
on moral grounds, and that it would be a waste of time to point out 
the means of reducing the mortality to which they must be subject. 
The same observation applies, though not with equal force, to lying-in 
hospitals. The danger of congregating large numbers of puerperal women 
within their walls is obvious, and can only be averted by a largeness of 
space and freedom of ventilation to which the expense must always be 
a serious obstacle. 

930. Of schools, it will suffice to remark that the contagious maladies 
to which children are subject render an observance of all the rules of 
health presently to be laid down for adults doubly necessary. 

931. To prisons attaches the necessary drawback of confinement at 
an age when the desire for active employment is at its height. The 
younger inmates of workhouses share this evil with prisoners ; and it is 
not to be doubted that when, to the evils of confinement in the case of 



218 PUBLIC HYGIENE. 

the healthy, are added those of sick-wards with inadequate accommoda- 
tion, limited space, and a scale of expense adapted, of necessity, rather 
to the means of the poorer ratepayers than to the strict necessities of 
the case, workhouses have always been, and must continue to be, highly 
destructive of life. 

932. Sailors on board ship, and soldiers on service, are exposed to 
special disadvantages ; sailors, to unusual narrowness of space, and to 
close confinement in rough weather, often combined with bad water, 
scanty and unwholesome i'ood, and great exposure and fatigue; soldiers, 
to the same evils, in nearly the same degree, and the superadded disad- 
vantage of equal exposure to t the weather, with less shelter, encampment 
on unhealthy spots, and prolonged occupation of badly-selected sites for 
barracks and hospitals. 

933. In treating of the means of preserving health and preventing 
disease among bodies of men there will have to be considered : 1. The 
case of persons confined within such buildings as prisons, workhouses, 
and barracks. 2. The case of the sick in hospitals. 3. The special 
case of persons living for a time on board ship, as sailors and emigrants. 
4. The case of sailors and of soldiers in actual warfare. 

934. 1. The means of preserving the health of persons confined within 
such buildings as prisons and workhouses are those already described in 
the beginning of this chapter as applicable to individuals and families, with 
a few obvious modifications. The buildings should be so constructed as 
to combine a healthy site and suitable aspect with good water supply, 
thorough drainage, spacious living and sleeping rooms, facilities for 
oversight and inspection, and ground for exercise and wholesome labour. 
The portions of the structure requiring drainage should be placed on the 
skirts of the building in such a manner as to obviate the necessity of 
carrying the drains under the building itself, and the earth-closet may 
be used with advantage. The walls should be surrounded by air-drains ; 
the lower story of the building should be so constructed that the floor 
shall not be in contact with the soil ; the purity of the air should be 
provided for by a space in living and sleeping rooms falling little short 
of 1000 cubic feet, and warmth and ventilation conjointly by open fire- 
places, and windows, glazed with thick glass, or with double panes of 
common glass, and opening above and below. In prisons, warming by 
hot air, hot water, or steam, and ventilation by mechanical aids, cannot 
well be dispensed with. In all other buildings these modes of warming 
and ventilating are highly objectionable, except for passages and halls, 
and for rooms occupied only occasionally, and for short periods of time. 
Scrupulous cleanliness is to be insisted on, not merely for its own sake, 
but for the occupation it gives ; facilities for exercise have not merely 
to be afforded, but exercise itself to be organized and superintended ; and 
the greatest care should be taken that the diet of the inmates consists of 
a due proportion of animal and vegetable substances, from which vege- 
tables or cheap fruits containing a vegetable acid, or such an acid in 
combination with an alkali, should on no account be omitted. This 



HOSPITALS. 219 

precaution requires to be especially borne in mind when the potato, 
which answers this description, falls short. 

935. 2. Hospitals, in common with buildings tenanted by bodies of 
healthy persons, should combine a well-selected site, a dry soil, thorough 
drainage, a suitable aspect, a compact arrangement of rooms and pas- 
sages favourable to efficient oversight and easy communication, and an 
economic system of warming and ventilation. The remarks already 
made on site, soil, and drainage, as applicable to houses, apply equally 
to hospitals, and a few additional words on the subject of aspect will 
supply all that is required on this head. 

The best aspects for the w T ards of an hospital are the north and south, 
or the north-west and south-east. The east and west aspects combine 
the advantages of greater cheerfulness with the drawback of the sun's 
glare ; and the west aspect is open in summer to the objection of great 
heat in the after part of the day. The south aspect is the best for con- 
sumptive patients, for those suffering from diseases of the lungs, for 
weak and delicate persons, and for the aged. In hospitals restricted to 
two aspects, the direct north and south are preferable to the direct east 
and west. In general hospitals with a north and south aspect, the 
southern wards are most suitable for diseases of the chest, for aged per- 
sons, and for the weak and delicate ; the northern wards for febrile and 
inflammatory disorders. For convalescent hospitals, the greater cheer- 
fulness of the east and west aspects is a recommendation. The airing 
grounds attached to hospitals should have a southern exposure. Dis- 
pensaries and rooms for the examination of patients should face north 
and south, and larders and provision- stores north. 

The most economical arrangement of an hospital is one which devotes 
the basement to the out-patient department, the dispensary, the living 
and sleeping rooms of nurses and subordinate officers, the kitchen and 
stores. 

A compact arrangement of rooms and passages is best obtained in a 
lofty building with a large central staircase ; and the most economical 
as well as least objectionable, arrangement for warming and ventilating 
is obtained by a combination of open fireplaces with the thick walls of 
a lofty building, and windows glazed with thick glass, or with double 
panes of thin glass, and opening freely above and below, or tilting in- 
wards in three or more sections. The air of the great central staiicase 
should be warmed by open fires, and be available in bad weather for the 
ventilation of the wards. 

As the wards of an hospital are occupied by sick persons day and 
night, the cubic contents per bed should be half as great again as in 
prisons, workhouses, and barracks. For adult males, and in the case of 
hospitals in London and the large provincial towns, it should not fall 
short of 1500 cubic feet; and in fever hospitals and lying-in wards 
: should amount to 2000. A considerable reduction of space may be made 
; in the case of women and children, and of hospitals in open situations 
in the smaller provincial towns. 

The wards of an hospital should be lofty as well as spacious. They 



220 PUBLIC HYGIENE. 

should have a height of 14, 15, or 16 feet, and such length and width 
as to give ample space round the beds. The beds arranged along the 
outer walls should stand each in a pier between two windows, and those 
of inner walls, opposite to them, and the corner beds should not touch 
the end walls. The windows should rise to within a short distance of 
the ceiling, and open above and below. The number of beds in a ward 
must vary with the kind of cases admitted. In civil hospitals, thirteen 
or fifteen beds in a ward are convenient numbers, especially as admitting 
of symmetrical arrangement ; in military hospitals, thirty beds is the 
number generally preferred. For an equal number of nurses or atten- 
dants, the number of beds in a ward will decrease with the severity of 
the cases, and vice versa. 

The same principles of arrangement and construction apply to mili- 
tary as to civil hospitals. Of camp hospitals, or of buildings used for 
soldiers in actual service, it may suffice to observe that the roughest 
weatherproof shed, provided it be spacious, is to be preferred to the most 
substantial building if overcrowded. This truth, distinctly proved by 
Dr. Brocklesby, is one which should never be absent from the mind of 
the army surgeon. 

936. 3. A ship on the open sea has the solitary advantage of being 
surrounded hj a pure air free from injurious terrestrial emanations. In 
all other respects it is placed under unfavourable circumstances ; for it 
combines the drawbacks of inadequate space for passengers and crew, 
and stowage of water and provisions ; of ventilation liable to frequent 
interruptions ; of a moist atmosphere acting on vegetable matters sub- 
ject to decomposition ; and of the frequent incursions of a water abound- 
ing in salts (the sulphates), which by decomposition evolves sulphu- 
retted hydrogen gas. A ship in harbour, though in other respects better 
circumstanced, is often exposed to the most deleterious emanations from 
low swampy lands and rich alluvial soils. A seafaring life, moreover, 
is exposed to great and continuous fatigues under circumstances otherwise 
unfavourable to health, and. to a certain extent, and often for long 
periods of time, to the evils of a monotonous existence. Hence the 
health of seamen and passengers by sea can only be preserved by the 
most watchful care and attention to the cleanliness, dryness, and venti- 
lation of the ship, the supply of fresh water, and of sound provisions 
embracing all the elements of a wholesome diet, with suitable clothes, 
and proper change of clothing, and with fitting exercise, occupation, and 
recreation. To these must be added facilities for separating the sick 
from the healthy. 

The means to be adopted to insure these ends can only be fitly de- 
scribed by those who add to a general knowledge of the principles of 
hygiene a special acquaintance with the construction and internal economy 
of ships. 

937. 4. The preservation of the health of soldiers and sailors in 
actual warfare is a subject which can only be adequately treated in works 
specially devoted to it. Men engaged in offensive wars are exposed at 
the same time, or in quick succession, to every cause of disease except 



SOLDIERS IX TIME OF WAR. 221 

inactivity of mind and body; and even from this they are not always 
exempt. They are often called on to serve in unhealthy climates and 
pestilential places, in inclement seasons, with inadequate shelter, or with 
no shelter at all, with short supplies of provisions, rarely of the best 
quality, and from which some important elements of a wholesome diet 
are almost necessarily omitted, exposed to every species of hardship and 
privation, to fatigue and want of rest, and they are sometimes tempted 
to dangerous excesses of riot and intemperance. When serving at a 
distance from home, they often enter on a campaign with health im- 
paired by the confinement of a long sea voyage, and must often remain in 
garrisons and encampments combining the most unwholesome sites with 
the most imperfect sanitary arrangements. Under such circumstances 
a close attention to all the known means of preserving health and pre- 
venting disease becomes imperatively necessary. Some of the leading 
precautions and provisions applicable to the soldier in service may be 
briefly stated. 

In transporting troops from place to place the same watchful care is 
required on board ship as in the case of sailors and passengers ; and when 
it is possible to choose the time of year, that should be selected which 
will enable the soldier to arrive at his destination at the healthiest 
season, and one bearing the nearest resemblance to his native climate. 
His clothing should be suited to the climate and season, being of close- 
fitting woollen materials in cold climates and in winter ; of cotton, sit- 
ting loose, and with protection for the head, in hot climates and in 
summer. In winter, flannel should be worn next the skin ; in summer, 
cotton. A warm waterproof cloak for wet weather and night use, and 
strong thick shoes well fitted to the feet, with thick woollen socks, com- 
plete the necessary clothing of the soldier. In all places, and at all 
times, mere soldierly appearance and bearing should give place to com- 
fort and practical efficiency. The best bedding for the soldier is a mat- 
tress stuffed with cork, covered beneath with waterproof cloth, and 
having a double flap of the same material to draw over the body. The 
soldier's diet should be as carefully adapted to the climate as his dress. 
In cold climates a full supply of animal food should be provided, and 
spirituous liquors are least injurious ; in warm climates an excess of 
vegetable food, and an abstinence from spirituous liquors, should be en- 
joined; in both, vegetables and ripe fruits, or their nearest substitutes, 
ought on no account to be omitted. The soldier on the march should 
be in motion during the hours most suitable for exercise, and for avoid- 
ing the intense heat of warm climates. He might always advantageously 
walk one or two miles before taking his first meal ; then, after rest and 
refreshment, enter on the principal portion of the day's march. The 
best food for the first meal is warm nutritious soup, or hot coffee with 
bread ; and tea is always a grateful refreshment. The ground chosen for 
encampments should, if possible, be sloping, so as to allow of natural 
drainage, protected from cold winds, and, in hot climates, affording the 
shelter of trees. Places for the deposit of offensive matters should be 
chosen in reference to the prevailing direction of the wind. They are 
best placed on a sloping bank, upon which dry earth should be thrown 



222 PUBLIC HYGIENE. 

day by day ; the mixed soil being removed at short intervals to a con- 
venient distance. Soldiers should not remain on the same spot for any 
length of time, but the site of the camp should be changed at short in- 
tervals. Proper arrangements should always be made for separating 
the sick from the healthy ; and, in providing tents, or huts, or more 
substantial buildings for hospitals, the principle already laid down should 
be constantly borne in mind, that the roughest shelter, with plenty of 
space, is preferable to the most substantial building without it. 

Soldiers in cantonments or bar'rachs often suffer severely through the 
selection of an improper site. Instead of being stationed on high sloping 
ground, some low-lying swamp at the mouth of a river is chosen, with 
the certain result of excessive sickness and a high mortality. If to this 
first fatal error there be added a similar neglect of other hygienic pre- 
cautions, the results are lamentable. If, on the other hand, a good 
choice of site is followed up by careful attention to all the simple rules 
of health, the soldier's life may be preserved even in the unhealthiest 
climates. 

In cantonments and barracks, and on the march, as far as the exi- 
gencies of actual warfare will permit, the following precautions should 
be carefully observed. The soldier should be sheltered, as much as pos- 
sible, from the heat of the day, and from the cold and dews of the 
night ; dry, healthy spots should be chosen for military exercises ; mili- 
tary duties should be so timed that the soldier may be deprived as rarely 
as possible of his natural sleep ; in mounting guard arrangements should 
be made to employ as few fatigue-parties as possible ; the messes should 
be so ordered that the soldier may begin the duties of the day with a 
comfortable warm breakfast ; the diet should always comprise a due 
supply of vegetables and ripe fruits, and the canteen should be placed 
under stringent regulations ; the means of personal cleanliness should be 
provided, and daily washing of the feet and frequent bathing be insisted 
on ; flannel waistcoats or cotton shirts should be worn next the skin, 
and a flannel belt round the loins ; and a change of clothing should be 
provided and ordered after every exposure to rain. The soldier should 
also be subject to frequent medical inspection, especially during the pre- 
valence of epidemics ; and he should be encouraged to engage in manly 
sports, should be employed to the utmost in useful and cheerful labours, 
and in studies calculated to occupy and amuse the mind. 

The subject of Public Hygiene would be incomplete if some notice 
were not taken of the dietaries adapted to preserve the health of men, 
women, and children when brought together in large numbers. A 
separate section may also be advantageously devoted to the subject of 
purification of air, water, and animal excreta?, to deodorants, disinfec- 
tants, and antiseptics. 

3. DIETARIES. 

938. The great pestilences of former times were always preceded or 
attended by famine or scarcity ; and a deficiency of food, or a failure of 
some important crop, such as the potato, has proved the immediate 
forerunner of the most fatal outbreaks of fever in more recent times. 



DIETARIES. 223 

Moreover, the relation which scarcity of food bears to one form of fever 
is so marked as to have led the best modern authorities to speak of it 
as " Relapsing, or Famine Fever." 

939. Scarcity of food, or the lack of some important element of a 
wholesome diet, has also given rise to many fatal maladies among 
soldiers in active service, and especially those engaged in the attack or 
defence of besieged places, as well as among seamen. 

940. The same cause has also been in occasional operation in all esta- 
blishments for the reception of healthy and sick persons — in schools, 
prisons, and workhouses, in barracks, and in hospitals ; and some notable 
and instructive examples of the danger attending large reductions in ex- 
isting dietaries, and the omission from the diet-roll of such an important 
element as the potato and its vegetable equivalents, have been afforded 
within the present century. One of the most painfully instructive of 
the.se cases occurred at Millbank prison in 1822 ; and some instances on 
a smaller scale in other prisons still more recently. 

941. The principal diseases which have been traced to scarcity of 
food, or to food of an improper character, are scurvy (purpura nautica 
and purpura hemorrhagica), dysentery, and diarrhoea, continued fever, 
and scrofula ; in infants, the disease known as tetanus neonatorum ; and 
in children, marasmus. All those maladies, bodily and mental, which 
follow upon gradual exhaustion of the strength, and impairment of the 
constitution, are also promoted by the same cause. 

942. Of the diseases just specified the one which is most certainly pro- 
duced by an insufficient diet, but especially by one from which vegeta- 
bles are excluded, is the scurvy — a disease which fortunately marks its 
presence not merely by extreme weakness, but by the characteristic 
swollen, spongy, and bleeding gums, the pouring out of blood in cir- 
cular spots (petechia?), or in irregular blotches beneath the skin, and 
haemorrhage from the mucous surfaces. 

943. In devising suitable dietaries for the inmates of public establish- 
ments, or for other bodies of persons, many circumstances must be taken 
into account, such as age and sex, occupation and manner of life, health 
and sickness, and the necessity, or otherwise, of economy. So large a 
subject can only be worthily treated by entering into details which 
would be out of place in this work ; but a few general principles appli- 
cable to all persons alike, and subject to modifications in accordance with 
age and sex, health and sickness, and the demands ma'le on the strength 
by different conditions and occupations, may be usefully laid down, re- 
lating to : — 1. The constituents of a wholesome dietary. 2. The pro- 
portions in which those constituents should be given. 3. The quantities 
required by adults of either sex, and by children of different ages. And 
4. The variations in quantity necessitated by condition and occupation. 

944. 1. The constituents of a wholesome dietary have been deter- 
mined partly by experience and partly by inference from chemical ex- 



224 DIETARIES. 

animation of the blood, structures, and excretions of the human body, 
on the one hand, and of different kinds of food on the other. Experience 
has taught us the necessity of blending in the same dietary more than 
one kind of food ; and has warned us in language not to be mistaken, of 
the danger of omitting from any dietary for any length of time that vege- 
table element of which, in consequence partly of its abundance and partly 
of the convenience with which it may be stored and kept, the potato is 
the best representative. By chemical analysis of the blood and animal 
structures, we have been taught that the body cannot be built up, 
nourished, ami maintained in health and vigour without such mixed food 
as shall supply it with the nitrogenous elements of muscle and skin, the 
carbonaceous element of fat, and the several mineral matters which enter 
so largely into the composition of bone, and furnish an essential element 
of the nervous tissue. Chemistiy has also taught us that of the excre- 
tions, some (as the exhalation from the lungs) abound in carbon, otheis 
(as the urine) in nitrogen and saline matters. On the other hand, we 
have been taught, by the same science, that all the elementary consti- 
tuents of the blood and tissues, and all the solid and gaseous elements 
of the excretions, exist in the food which we consume and the air we 
breathe, and can be traced to them ; and, further, that it is possible to 
arrange all the varieties of food in two great classes, according as they 
contain or do not contain nitrogen r § 167), the non-nitrogenous class 
subserving the function of respiration, and contributing largely to the 
production of heat ; the nitrogenous or plastic class, employed in build- 
ing up, maintaining, and repairing the tissues of the body. 

945. The chemical analysis of the milk by which young animals are 
nourished, and of the egg which performs the same office tor birds, con- 
firms the information derived from the sources just indicated ; for the 
solid matter of milk consists of more than a third of its weight of the 
nitrogenous element, caseine ; somewhat more than a fourth of the car- 
bonaceous material, oil or butter ; and less than half of another carbona- 
ceous element, sugar : these, with about a hundredth of its weight of 
mineral substances, of which by far the larger portion is phosphate of 
lime, being held dissolved or suspended in about eight times their weight 
of water. Here we have a nitrogenous or plastic element (caseine), 
combined with carbonaceous elements in the proportion of about one to 
three. In the egg, again, the nitrogenous element, albumen, in the pro- 
portion of about seven parts, is blended with oily matter (a small quan- 
tity of sugar only being present) in the proportion of rive parts, these 
matters being mixed with about three times their weight of water. 

Again, chemical analysis of the vegetable substances which expe- 
rience has proved to be preventives of scurvy, have shown that it is 
not by virtue of their carbonaceous or nitrogenous constituents that they 
so act, but by means of a vegetable acid (the citric or malic), free, or 
combined with potash. 

946. It follows, then, from the teachings of experience, and the re- 
searches of the chemist, that a dietary to be wholesome and nutritious 
must contain a combination of nitrogenous or plastic, and non-nitro- 



DIETAEIES. 225 

genous or respiratory, elements, together with vegetables known to 
contain a free acid, or such an acid in combination with potash. 

947. Now, some artxles of food in common use are rich in nitrogen, 
others in carbon, and others, again, contain both elements blended in 
proportions approximating more or less closely to the actual require- 
ments of the frame. So that it is quite possible to construct wholesome 
and nutritious dietaries by very different combinations of food. One 
diet may have milk for its chief" element, another the flour of wheat or 
other cereal, another meat, another fish, another the potato. In India 
rice is the staple of diet, in Ireland the potato, in Scotland oatmeal, in 
England the flour of wheat. 

948. For practical purposes the substances most used in the dietaries 
of this country may be classed as nitrogenous, carbonaceous, and mixed 
— the first group consisting of meat, cheese, and pease ; the second of 
suet, bones, and molasses, rice, and the potato ; and the third of milk, 
and the flour and meal of wheat, oats, barley, and maize. The common 
vegetables which contain a free acid, or an acid in union with potash, 
are potatoes, turnips, and carrots. Cabbage and onions have the same 
antiscorbutic property, but with a nitrogenous element. Milk also has 
the same valuable property, in virtue of the free acid which sometimes 
exists in it, and which is always readily produced by fermentation. 

949. The cheapest articles which may be readily and abundantly pro- 
cured in this country are:— among the nitrogenous group, shins of beef 
(meat and bone together for soup), butter-milk and skimmed milk, and 
pease; among the carbonaceous group, bones, suet, molasses, potatoes, 
and rice ; and among the mixed group, Indian meal, barley-meal, oat- 
meal, and wheaten flour. 

950. This grouping has no pretence to scientific accuracy ; for, with 
the exception of suet and molasses, the rest consist of combinations of 
the nitrogenous and carbonaceous elements in different proportions, the 
nitrogenous group having a larger proportion of nitrogen, the carbona- 
ceous group of carbon, and the mixed group the two elements in pro* 
portions which peculiarly fit them to become the substantial centre or 
basis of a wholesome and nutritious dietary. 

951. These elements of a cheap dietary are very variously combined 
in actual practice. Indian meal and oatmeal are usually mixed with 
milk into a pudding or porridge ; suet with wheaten flour into a pud- 
ding ; the bones and flesh of the shin of beef with onions, carrots, and 
pearl-barley, into a nutritious soup ; bread is eaten with cheese ; and the 
potato, in the best devised dietaries, forms a part of every dinner. 

952. 2. The proportions in which these, the chief constituents of a 
wholesome dietary, ought to be blended, have been ascertained with some 
approach to accuracy by a chemical comparison of the food consumed 
and the excreta discharged, by adult males of the well-fed class most 
readily submitted to experiment. If Dr. Dalton's experiments on him- 
self might be taken as a standard, it would follow that an adult healthy 



226 DIETARIES. 

male ought to be supplied with articles of food containing about eleven 
and a half ounces of carbon and an ounce and a half of nitrogen (§ 257). 
The nitrogen should, therefore, bear to the carbon the proportion of 
about one to seven, or one to eight. Yierordt expresses the wants of 
the adult frame somewhat differently. He says that an adult male, to 
keep in good condition, requires about four ounces of albuminous matter, 
nearly three of fat, and about ten and a half of amylaceous food daily. 
One pound of wheat en bread, one pound of potatoes, and about four 
ounces of me it, or its equivalent in nutritious meat-soup or cheese, per 
diem, would fahly meet this requirement. If it were deemed expedient 
to exclude the meat element, one pound of bread, half a pound of pota- 
toes, half a pound of oatmeal, and seven pints of milk per diem, would 
similarly meet the theoretical requirements of the German physiologist. 

953. By very general assent it has become the practice in England 
to supply to paupers and prisoners a dietary consisting chiefly of bread, 
potatoes, and meat, soup containing meat, and gruel for breakfast. A 
liberal, but not excessive, diet for men not at hard work might be roughly 
stated to consist of about 275 ounces per week of food served in the solid 
form, and about fourteen pints in the liquid form ; while for men at 
hard labour the quantity of solid food is generally found to exceed 300 
ounces per week, the liquid food being still about fourteen pints. 

954. The quantities of food required by adult men and women, and 
by children respectively, are not easily ascertained. One obvious con- 
sideration arises out of the weight of the classes to be provided for. 
Thus, the weight of an adult woman being about a sixth less than that 
of an adult man, it would be reasonable, if all other things were equal, 
to deduct a sixth from the dietaries of adult males, in order to adapt 
them to the use of adult females. But as the work of nutrition goes 
on less actively in women, and the wear and tear of their system is less, 
the deduction may perhaps be roughly represented by a fourth of the 
food served in the solid form. So also, as the weight of men or women 
at sixty-five or seventy years of age is about a twentieth less than the 
weight of adults, and their functions much less active, it would not be 
unreasonable to reduce the dietary of aged persons by at least a tenth. 

955. The case of children offers greater difficulty ; but here, too, the 
element of weight cannot be disregarded. A child five yearns old will 
weigh about a fourth, a child of seven about a third, and one of fourteen 
not much more than the half of an adult of the same sex ; but as the 
child is growing, it is obvious that it requires, in comparison with the 
adult, a quantity of food not to be measured by the weight alone. 
Hence, instead of a fourth, a child of five years might require a third 
of the food given to the adult, a child of seven might require a half, 
and a young person of fourteen as much as two-thirds. Assuming the 
weekly diet of an adult to be 300 ounces of solid food, consisting chiefly 
of bread, potatoes, and meat, the solid constituents of the dietary of the 
Foundling Hospital, as given by Pereha, would amount for children 
under nine vears to about five-twelfths, and above nine to about seven- 



DEODORANTS. 227 

fifteenths. The liquid portion of the food in these dietaries for children 
consists very properly of milk. In adult dietaries milk is used excep- 
tionally. 

956. 3. Of the variations in the quantity of food rendered necessary 
by condition of life and occupation, it may suffice to observe that, as a 
general rule, inaction of mind and body imply a moderate allowance, and 
activity of mind and body a liberal supply ; that bodily exertion neces- 
sitates an increase, and bodily inaction a decrease of the nitrogenous or 
plastic elements ; and that a liberal supply of the vegetable element, of 
which the potato is the most convenient representative, is specially needed 
in men or women who lead an inactive life within doors. It is believed, 
too, that convicts, in consequence partly of their long confinement, and 
partly of the depressing effect of imprisonment, require a more liberal 
diet than paupers ; and that convicts with long sentences must be better 
fed than prisoners whose term of retention is shorter. It is probable 
that as the depression produced by imprisonment has been over-esti- 
mated, so also has the need of a more sustaining diet; and it is quite 
possible that an increase of the vegetable (potato) element would meet 
this exceptional case better than an absolute increase in the quantity of 
the food. 

4. DEODORANTS, DISINFECTANTS, AND ANTISEPTICS. 

957. The medical man may have to give advice as to the choice and 
use of these agents in the sick-room, when it is not possible to resort to 
a thorough draft of air to sweep away the offensive odours emanating 
from the patient or his excreta, and in cases of fever or the febrile ex- 
anthemata, in order to render inert or harmless the contagious matters 
which float in the air, or attach themselves to clothing, bedding, and fur- 
niture. He will also naturally be consulted respecting the purification 
of air, water, and offensive refuse matters ; and, if officially engaged in 
the prevention of disease, the ordering of such works of purification will 
constitute no inconsiderable part of his duties. 

958. In treating this subject, the chief deodorants, disinfectants, and 
antiseptics, will first be named and classified, and then those among them 
which are best adapted for special purposes will be pointed out. 

959. 1. Deodorants, or agents which remove, or destroy, odours. 
These are either dry solid matters (such as charcoal," lime, earth, or 
ashes) which act by absorbing, or combining with, the water and gases 
of the odoriferous material ; or, 2. Inodorous saline solutions, of which 
the acid, the base, or both, combine with some element of the gas or 
gases to which the material owes its offensive properties (such as per- 
manganate of potash, chloride of zinc, perchloride of iron, nitrate of lead, 
sulphate of iron, and the mixed sulphates of zinc and copper; or, 3. Salts, 
and their solutions, which readily give off gaseous matters (such as the 
chlorides of lime, potash, and soda, which yield chlorine) ; or, 4. Liquids 
giving off acid vapours which combine with the ammonia of the sul- 
phide and other ammoniacal compounds (such as vinegar and pyrolig- 
neous acid) ; or, 5. The gases, chlorine, iodine, bromine, ozone, nitrous, 



228 DEODORANTS, DISINFECTANTS, AND ANTISEPTICS. 

and sulphurous acids, and ammonia. The smoke of coarse brown paper, 
of cascarilla bark, of benzoin, of juniper berries, of pastiles, &c, is to be 
considered as concealing; rather than correcting offensive odours, and is 
not, therefore, rightly classed among deodorants. The vapours of burn- 
ing tar or pitch, and those perhaps of the resins generally, may, how- 
ever, be rightly admitted into the class, as well as the smoke of burning 
paper saturated with nitrate of potash. 

960. 2. Disinfectants, or agents which destroy infectious matter. 
This class is smaller than the foregoing, and comprises only a few of its 
more active members ; and the efficiency of some of them is rather in- 
ferred from their known chemical activity than proved experimentally ; 
for the exact nature of infectious germs is as yet unknown. The most 
approved disinfectants are — a. Heat. A temperature of 212° Fahr., ap- 
plied as hot air, steam, or water, during the space of from half-an-hour 
to an hour effectually destiovs infectious matters. — b. Chemical vapours. 
Among deodorants those that are most likely to answer the purpose 
of disinfectants also are chlorine, biomine, and iodine, ozone, and ni- 
trous, hydrochloric, and sulphurous acid gases. — c. The tar acids (carbo- 
lic, cresylic, and creasote), of which Carbolic acid is the most efficient. 
The researches of the Cattle Plague Commission of 1866, conducted by 
Dr. Angus Smith and Mr. Crookes, have issued in proving the un- 
doubted superiority as disinfectants of sulphurous acid gas, generated by 
burning sulphur, and carbolic acid more or less diluted with water. The 
choice was understood to lie between these and the powerful oxidizing 
agents, chlorine and ozone, and the former were preferred. 

961. 3. Antiseptics, or agents which arrest or prevent fermentation 
and putrefaction. The most efficient members of this class are — a. a 
high or low temperature, as of 212° Fahr. on the one hand, and 32° 
Fahr. on the other. — b. Sulphur-fumes and carbolic acid, as proved by 
the researches just referred to. 

962. In making choice of one or other of these agents in special cases, 
we must be guided by the character of the material to be cleansed or 
purified. In empty rooms or buildings, or for the cleansing of floors or 
walls, burning sulphur, strong solutions of carbolic acid, and the several 
substances which give off bleaching or corrosive acid fumes, may be freely 
employed : they are less applicable to rooms containing furniture. The 
dry deodorants — charcoal, lime, earth, ashes, and sulphate of iron, — are 
specially applicable to feculent discharges, as is also the permanganate 
of potash in solution. Water containing animal matter may be treated 
with a dilute solution of permanganate of potash, and water which owes 
its hardness to bicarbonate of lime held in solution, may be softened by 
the use of milk of lime. The air of sick rooms may be purified by the 
chlorine given off from the moist chloride of lime, or by solutions of the 
permanganate of potash fieely exposed on cloths moistened with it. The 
odour of feculent matters diffused through the sick-room quickly dis- 
appears on burning coarse brown paper saturated with nitrate of potash. 
The common disinfectants are sold in shops, with directions for use. 



229 



CHAPTER VI. 

GENERAL THERAPEUTICS. 

963. The Science of Therapeutics treats, as the name implies, of the 
cure and palliation of diseases. In its widest sense, it comprises all in- 
formation having a direct bearing on the knowledge of disease - , on the 
one hand, and of remedies on the other. The application of this know- 
ledge constitutes the Art of healing. 

964. The art of healing is beset by the same difficulties that attach 
to the study of disease, and by others peculiar to itself. As our imper- 
fect acquaintance with the phenomena of health limits our knowledge 
of disease, so our scanty knowledge of the action of remedies on the 
healthy frame is an obstacle to the successful treatment of disease. But 
still greater obstacles result from the difficulty of instituting compara- 
tive trials of different modes of treatment in the same disease, and our 
ignorance of the extent to which the body, if left to itself, would repair 
the iu juries which it sustains. We cannot leave disease to itself; hence 
we are ignorant of the power of the "vis medicatrix:" and we are re- 
luctant to employ a new remedy in a disease in which an old one is used 
by general consent, lest an unsuccessful or fatal result should be laid to 
our charge. 

965. To form an exact classification of remedies, or to establish broad 
principles of treatment, is, therefore, a work of great difficulty. What 
we know on the subject will be best explained by taking the principal 
functions of the body, as described in a former chapter, and showing the 
effect of remedies on each of them in turn. In pursuance of this plan, 
the following arrangement will be adopted : — 

(1.) Remedies applicable to disorders of the primae vise, including the 
treatment of those of the stomach, liver, and intestines. (§§ 142 to 188.) 

(2.) Remedies which modify the composition of the blood. (§§ 189 
to 258.) 

(3.) Remedies which affect the circulation and the functions of the 
several orders of vessels. (§§ 259 to 361.) 

(4.) Remedies which act on the structures of the body. (§§ 362 to 
406.) 

(5.) Remedies which act on the nervous system. (§§ 407 to 466.) 

(6.) The duties of the nurse and the management of the sick-room. 



230 GENERAL THERAPEUTICS. 



1. KEMEDIES APPLICABLE TO DISEASES OF THE PB.UIJE VIJE. 

966. Diet. — Most disorders of the stomach require regulation of the 
diet, and directions as to the time and mode of taking i'ood. The most 
common functional disorder is anorexia, or loss of appetite, attendant on 
almost all severe diseases, especially those of an inOammatory or febrile 
character. It always indicates a loss of power to digest food, and neces- 
sitates either entire abstinence, or the use of such articles of diet as are 
least irritating to the stomach ; such as barley-water, toast-water, milk- 
and-water, and weak tea ; acidulated drinks, such as lemonade and 
imperial; and the ripe juicy fruits, especially the orange and grape. 

967. The functional disorders of the stomach which originate within 
the organ itself, are known as acute and chronic dyspepsia. The acute 
form requires a diet free from all matter which can irritate the tender 
membrane of the stomach ; such as gruel, arrow-root, or sago, made 
with or without milk, to the entire exclusion of solid matters, whether 
animal or vegetable. The chronic form requires a close attention to the 
time and mode of taking food, the quantity and quality of the food itself, 
and the state of other parts of the alimentary canal, especially the large 
intestines, as well as that of the liver. Complete mastication, a mode- 
rate quantity of liquid and of solid food, a sparing use of condiments, 
and moderate intervals between meals, are points always to be insisted 
on. The diet suitable to each patient is, to a certain extent, a matter 
of experience, and distressing symptoms (such as palpitation with an 
irregular or intermitting pulse j have sometimes been removed by omit- 
ting some article, such as tea, from the diet-roll ; or by substituting 
unfermented for fermented, bread. 

968. In organic diseases of the stomach, as in acute dyspepsia, ab- 
stinence from solid and irritating matters is indicated ; but such sub- 
stances must be prescribed as are nutritious, and yet unirritating ; such 
as strong broths, soups, and jellies. When the stomach is unable to 
retain any food, life may be prolonged by nourishing enemata ; by fric- 
tion of the skin with oily matters ; or by local baths of warm nutritious 
liquids. 

969. There is a class of patients in whom much depends on the se- 
lection of food suitable to their age. This is especially the case in the 
diseases of children. Solid food of every kind is apt to disagree with 
veiy young children : it disorders the stomach and bowels, gives rise to 
infantile remittent fever, developes the scrofulous'taint, and, if unchecked, 
terminates in hydrocephalus or mesenteric disease. Such children re- 
quire a strict regulation of the diet, an abstinence from solid food, and, 
in extreme cases, a recurrence to the diet of the infant at the breast, sub- 
stituting for the milk of the mother, asses' milk or new milk from the 
cow, and administering it, if necessary, in small quantities, and at long 
intervals. This simple treatment, aided by the steady use of aperients 
when required, is often attended with the best effects, after nourishing 



ANTIPHLOGISTIC DIET. 231 

and stimulating food, given with a view of imparting strength, has 
wholly failed. 

970. These disorders of the stomach affect chiefly its reducing func- 
tion. When its converting function is disturbed, the diet must be re- 
gulated in accordance with the existing disorder. In cases of diabetes 
mellitus, for instance, such a diet is prescribed as is least convertible into 
sugar. The saccharine staminal principles, therefore, are given in small 
quantity, and the diet is made to consist chiefly of albuminous and 
oleaginous elements. The substitution of gluten bread for common bread 
is also believed to be indicated in this disease. But the^e restrictions of 
the diet in diabetes are dictated by a theory of doubtful soundness, that 
when we cannot attack the cause or source of the disease, we ought to 
render difficult or impossible the development of its leading symptom. 
It is possible that a diabetic patient may thrive as well on a diet which 
supplies the elements of sugar, as on one that withholds them. To 
prescribe sugar itself is to push this theory to an unjustifiable limit. 

971. A less strict attention to diet is necessary in the subjects of the 
oxalic diathesis, in whom it may suffice to forbid the use of crystallized 
sugar. 

972. Strict dietetic rules have sometimes to be enforced as means of 
inducing certain states of the system. The strength and power of en- 
durance developed during training for the ring, are partly due to the 
diet prescribed ; and the reduction of weight ill the jockey is effected in 
part by an opposite dietetic treatment. The results obtained by Mr. 
Banting, who reduced his weight in one year from 202 to 156 pounds 
by abstinence from bread, butter, milk, sugar, potatoes, and bee]', afford 
a more complete illustration of the power of dietetic restrictions. In 
the practice of medicine diet plays an important part. Thus we allow 
a nourishing diet to the convalescent, and restrict a patient with a severe 
inflammatory or febrile attack to substances containing little or no nu- 
triment; the antiphlogistic diet or regimen being more or less strict, 
according to the severity of the disease. In the most severe cases total 
abstinence from food may be necessary, liquids alone being allowed to 
allay thirst : in less severe cases, the patient may be restricted to a 
vegetable diet, as having little effect on the circulation. 

973. During convalescence from acute diseases strict attention has to 
be paid to the powers of the stomach, as tested by the appetite, and to 
the state of the circulation, as evidenced by the pulse ; and we pass with 
caution from the strict antiphlogistic regimen to vegetable diet, from 
that to fish or light broths, and then to meat in moderate quantity, 
beginning with mutton, as most easy of digestion. 

974. In prescribing an appropriate diet, it should be borne in mind 
that vegetable food has little or no effect on the circulation, but that 
animal food acts as a stimulant ; that warm liquids excite, while cold 
liquids act as sedatives ; and that food affects the circulation most in 
the early part of the day. It is in cases of slow and unsteady con- 



232 GENERAL THERAPEUTICS. 

yalescence, when there are Forne remains of local affection, when the ap- 
petite is variable, and that condition of the general system exists known 
as ' irritation,' that these facts must be applied in practice. Wheu the 
patient, though weak, is free from disease, when the appetite is good, 
and the circulation tranquil, food may be given with less caution. 

975. But there are cases in which a nourishing and even stimulating 
diet is necessary, though local inflammation and constitutional irritation 
be present, and the appetite for food is almost wanting. To this class 
belong exhausting discharges, and extensive injuries in course of repara- 
tion, for which we prescribe solid food of the stronger and more stimu- 
lating kind, with the nutritious and stimulant liquids, wine, ale, porter, 
&c. In such cases, too, the previous habits must be attended to, and 
the drunkard must be supplied with his accustomed stimulus. 

976. As a general rule, where diet is equally efficacious with medi- 
cine, it should have the preference: for the duty of the physician is not 
to cure disease by physic, but by the most simple and efficacious means 
at his command. 

977. Acute affections of the mucous membrane of the stomach may 
often be cured by diet alone. It is only occasionally necessary to apply 
leeches or blisters to the epigastrium. But for chronic dyspepsia both 
diet and medicines are required. 

978. Many substances which increase the appetite and stimulate the 
stomach are in common use as condiments. Of these, common salt is 
the only one absolutely required ; for experiment has shown that animals 
deprived of it soon perish, however nourishing their food in other 
respects ; and one of the severest punishments to which man has ever 
been subjected, is a diet without salt. But when the diet consists prin- 
cipally of vegetables, spices are to be commended, as promoting digestion. 

979. Almost every substance possessed of active properties increases 
the vascularity of the mucous membrane, and the flow of its secretion, 
and stimulates the muscular coat to contraction. The rubefacients, for 
instance, or substances which inflame the skin, inflame the mucous mem- 
brane of the stomach too ; and many substances which cannot act on the 
skin through the cuticle, affect the more delicate and less protected 
lining of the stomach. In small doses these substances increase the appe- 
tite and stiengthen digestion; but in large doses they act as emetics. 
Thus, common salt, which in moderation is the best and safest condi- 
ment we possess, in large doses produces sickness, and in still larger 
ones is an irritant poison. 

980. Substances which act as emetics in large doses, are gentle stimu- 
lants in small ones ; and from among these we select our condiments. 
Similarly acting substances are given as medicines in dyspepsia, or to 
qualify remedies directed to other organs. Thus, we combine mint, 
ginger, or cloves, with saline purgatives, ammoniacum with squills, gal- 
banum with aloes, the essential oils with aperient pills. 



EMETICS — CHOLAGOGTJES. 233 

981. The simple, the warm aromatic, or the astringent, bitters, 
under the names of aromatics, stomachics, carminatives, or cordials, are 
the remedies most frequently employed with a view of increasing the 
appetite, or causing the fibres of the stomach to contract. Ginger, mint, 
and cardamoms are among the best remedies of this class. 

982. Emetics. — The remedies just enumerated, given in large doses, 
are emetics. Those in common use are ipecacuanha, tartar- emetic, and 
zinc ; and mustard or common salt, on an emergency, w T hen other emetics 
are not at hand. It is usual to promote the action of these substances 
by copious draughts of warm water, and by tickling the throat with a 
feather. Emetics are commonly prescribed merely with a view to un- 
load the stomach ; for this purpose they are often given at the out- 
set of febrile affections. But they are also administered at intervals, 
with good effect, in incipient cases of phthisis pulmonalis, and in bron- 
chitis accompanied with profuse expectoration. Emetics of common salt 
(three table-spoonfuls to a quart of water) have been prescribed with a 
view of producing reaction in the collapse of Asiatic cholera. 

983. The stomach becomes less sensible to stimulants if often repeated : 
so that what was an emetic at first becomes a promoter of digestion ; 
while a more gentle stimulant loses its effect entirely by repetition. 
Thus, a first cigar causes vomiting ; but the habitual smoker finds that 
tobacco promotes digestion. The same thing occurs in disease. The 
first few doses of tartar-emetic often cause sickness ; but the stomach be- 
comes accustomed to its use, and, if continued, it produces an amount of 
stimulation favourable to digestion. 

984. The remedies just mentioned, though differing little in their 
direct action on the stomach, vary gieatly in their remote action on other 
organs, some belonging to the class of stimulants, others to that of tonics, 
and the most active being strong irritant poisons. 

985. Both condiments and emetics eause a determination of blood to 
the mucous membrane ; cold liquids and ice have the opposite effect, and 
are therefore to be commended in acute inflammation of the stomach, or 
active haemorrhage from its surface. In chronic determination of blood, 
and in passive haemorrhage, nitrate of potash in full doses may be ad- 
ministered with advantage. 

986. Neuralgia of the stomach (gastrodyne) is often effectually re- 
moved by bismuth, zinc, and oxide or nitrate of silver, and troublesome 
sickness by creasote ; as also by dilute hydrocyanic acid — a remedy of a 
different class. 

987. The Liver, — The functional disorders of the liver, which consist 
in a diminished secretion of bile, are most effectually treated by small 
doses of mercury, or by nitro-muriatic acid, either taken by the mouth, 
or applie ^externally, as a foot-bath. Taraxacum and podophyllin are 
also given to increase the biliary secretion, for which purpose the remedy 
last named is extremely effective. Such remedies are termed cholagogues. 



mov( 



234 GENERAL THERAPEUTICS. 

Intestinal Canal. — The chief functional disorders of the intestinal 
canal are diarrhoea, haemorrhage, and constipation. 

988. Diarrhosa, like dyspepsia, may be acute or chronic. Acute and 
recent diarrhoea, like acute gastritis, may always be removed by a fari- 
naceous diet, from which ail solid and irritating matters are excluded. 
It will also generally yield to a single full do.-e of castor oil. Chronic 
diarrhoea, from a congested state of the mucous membrane, may be cured 
most effectually by acting on the liver with small doses of the remedies 
just named (§ 987). If this treatment fails, which it may do in very 
relaxed conditions of the mucous membrane, astringents (chalk mixture, 
aromatic confection, catechu, kino, tannin, &c.) may be resorted to. 
When these fail, stronger mineral astringents, as sulphate of copper, 
combined with opium, may succeed, and nitrate of potash sometimes 
cures when these have failed. 

989. Dysenteric diarrhoea, characterised not by profuse mucous dis- 
charges, but by scanty and teasing evacuations of a gelatinous substance, 
or of mucus mixed with blood, is best treated by full doses of castor-oil, 
with laudanum, following small doses of some mild mercurial prepara- 
tion, or of podophyllin, given at night. Such action on the liver is es- 
pecially indicated in chronic cases. The dysentery of warm climates, 
and of armies, is a disease which varies greatly in different cases, and in 
different epidemics, sometimes being highly inflammatory, and requiring 
antiphlogistic treatment, sometimes combined with scorbutic symptoms, 
and a degree of debility contra-indicating all active measures. 

990. Hcem.orr7io.ge from the intestines (melsena) requires the same 
treatment as chronic diarrhoea — viz., small doses of mercurial prepara- 
tions, or podophyllin, to act on the liver, and unload the vena porta?, 
and an unirritating diet. 

991. Haemorrhage from the bowels also occurs in dysentery; and in 
persons suffering from internal or external piles ; and occasionally florid 
blood flows in large quantity from the open mouth of a single artery. Ipe- 
cacuanha and opium have been found eminently serviceable in dysentery. 
Piles are relieved by unloading the bowels, by promoting the secretion 
of the liver, by the local abstraction of blood, and the local application 
of warm or cold water, according to the experience of the patient. The 
arterial haemorrhage is detected by the use of the speculum ani, and 
cured by the application of nitric acid to the bleeding vessel. 

992. Constipation, as it arises from many causes, requires many reme- 
dies. The substances which naturally promote the action of the bowels 
are those innutritious matters that escape the action of the stomach ; 
such as the cuticle and spiral vessels of vegetables, the hard covering of 
seeds, the tendons and gristle of meat. When these are carefully removed 
in the process of cookery, constipation is apt to arise, and may often be 
removed by restoring some of them to the food. Thus, brown bread 
often proves an effectual laxative. Constipation also occurs in persons 
of sedentary habits, and disappears under active exercise. 






PURGATIVES. 235 

993. The medicines that cause vomiting when taken into the stomach, 
as tartar-emetic, tobacco, sulphate of zinc, ipecacuanha, squills, &c, 
and the whole class of irritant poisons, act as purgatives when they 
pass into the bowels ; but many of the substances which act as violent 
purgatives have little or no effect on the stomach. 

994. Purgatives act in two ways — by promoting the secretion of the 
mucous membrane, and by increasing the peristaltic action of the intes- 
tines ; but some act slightly in one of these ways and energetically in the 
other. Those that excite abundant watery discharges are called drastic 
or hydragogue cathartics. 

995. Medicines that act on the bowels may be divided into groups or 
classes. There are the laxatives (manna, cassia pulp, tamarinds, prunes, 
honey, bitartrate of potash, castor, almond, and olive oils) ; the saline 
or antiphlogistic aperients (sulphates of soda, potash, and magnesia) ; 
the milder acrid aperients (senna, rhubarb, and aloes) : the strong acrid 
purgatives (as jalap, scammony, black hellebore, camboge, croton oil, 
colocynth, and elaterium) ; and, lastly, the hepatic purgatives (hydrar- 
gyrum c. creta, pilula hydrargyri, calomel, and podophyllin). 

996. We choose one or other of these remedies, according to the 
object we have in view. If we wish simply to relieve the bowels, we 
prefer the compound rhubarb or colocynth pills, or combinations of aloes 
with rhubarb or ipecacuanha ; if to promote the secretions of the whole 
course of the intestinal canal, we use the gentle laxative ; if to reduce 
inflammation, the saline ; if to overcome obstinate constipation, the 
stronger purgatives ; if to remove dropsical effusions, the drastic or hy- 
dragogue cathartics ; and if to promote the secretion of the liver, we com- 
bine the hepatic purgatives with those adapted to fulfil other indications. 

997. The choice of purgatives is not more important, however, than 
the mode of administration. When the bowels have been long overloaded, 
and especially when the local irritation has affected the nervous centres, 
it is important to remove the load from the intestines without increasing 
the mischief already existing ; in other words, hypercatharsis must be 
carefully avoided. Here we must not only select such purgatives as 
effectually remove the feculent matter, but watch their operation from 
day to day ; and as soon as any signs of intestinal irritation make their 
appearance, we must withdraw our purgative, and treat the hyperca- 
tharsis by a farinaceous diet, as if it were ordinary diarrhoea. 

998. In cases of extreme irritability of the stomach or bowels we may 
relieve the intestines by enemata, consisting of warm water, or gruel 
with or without an admixture of common salt ; or we may employ, in 
the same way, any of the ordinary aperient remedies. We may also act 
on the bowels by rubbing into the skin of the abdomen croton oil com- 
bined with castor oil. The shock of cold water to the abdomen, some- 
times employed with advantage in cases of obstinate constipation, or the 
electric spark, will also produce a purgative effect. 

Enemata containing turpentine or an essential oil, such as the oil of 
rue, are often advantageous in the painful flatulent distension of the 



236 GENERAL THERAPEUTICS. 

abdomen that occurs in many cases of fever as well as in other states ot 
system. They are most effective when thrown into the bowels by the 
long elastic tube. Enemata of salt dissolved in gruel are also often ad- 
ministered for the removal and cure of worms, especially of the thread- 
worm. 

2. REMEDIES WHICH MODIFY THE COMPOSITION OF THE 
BLOOD. 

999. All articles of food, and all poisons and medicines (even the least 
soluble), find their way into the blood. Those substances which enter 
naturally into its composition, when taken in quantities proportioned 
to the wants of the frame, are used in building up the fabric of the 
body ; but when taken in excess, they undergo change and are eliminated 
by one or other of the excreting organs. Poisons and medicine, in like 
manner, mixing with the blood, circulate with it, and pass away gra- 
dually, and often slowly, in the excretions, so as to come in constant 
contact with the textures of the body. 

1000. In the treatment of disordered states of system, and of diseases 
properly so called, we sometimes aim at a cure by administering such 
articles of diet or medicine as will supply some defective element of the 
blood ; but sometimes we purposely introduce a substance foreign to its 
composition, in order to destroy or counteract some injurious or poison- 
ous material to which the diseased condition owed its origin. The sub- 
stances of the first order are termed Restoratives ; those of the second 
order Catalytics. 

1001. Restoratives. — The class may be distributed into two sub- 
classes. (1.) This comprises water and every species of wholesome 
food, when the body is suffering from the want of them. Thus water 
has the virtue of a medicine after long marches, in starved and wounded 
persons, in some forms of poisoning, in profuse discharges of blood, 
and in diseases accompanied by excessive secretion ; and there are cases 
in which a limited use of water may act beneficially. A nutritious 
animal and vegetable diet is as medicine to the convalescent ; a spare 
diet, consisting chiefly of vegetables, to the plethoric and gouty patient. 
Fresh vegetables and ripe fruits are a panacea in scurvy ; fatty and 
oily substances of some service in phthisis ; animal and vegetable mat- 
ters not containing sugar, and not easily converted into it, are pre- 
ferred in diabetes mellitus ; sugar in a crystallized form is forbidden 
in the oxalic acid diathesis, and fatty matters are contra-indicated in 
disease of the pancreas. (2.) This consists of those medicines,, properly 
so called, which supply an element wanting to the blood. Such are iron 
and its preparations in anaemia and in allied states of system ; such are 
alkalies and acids respectively, when from the acid or alkaline reaction 
of the mine we infer an excess of acid or of alkali in the blood. The 
whole class of vegetable tonic medicines, of which quinine is the most 
important, is believed by some authorities ^see Headland on the Action 
of Medicines) to act favourably in states of debility by supplying to the 
blood an element closely allied in composition to the taurin of the bile. 






MEDICINES THAT ACT ON THE CIRCULATION. 237 

1002. Catalytics. — The medicines of this class are believed to be able 
to destroy or neutralise certain morbid poisons existing in the blood. 
Mercury acts thus on the syphilitic poison, especially when recently 
introduced into the system; and iodide of potassium when it displays 
itself in secondary symptoms, and particularly when the periosteum is 
affected. Again, mercury, in an eminent degree, and the fixed alkalies 
in a less marked manner, possess the power of checking inflammation — 
a power attributed, at least in part, to their well-known property of 
rendering the fibrin of the blood more soluble. The nature of the change 
which arsenic produces in the blood is less obvious, though its efficacy 
is undoubted ; and the same observation applies to iodine and antimony. 

1003. The more active medicines which exert a control over inflam- 
mation also excite it when locally applied ; and it admits of question 
whether this action is due to some change in the blood of the part, or in 
the state of its small vessels. The same difficulty presents itself when 
we try to explain the effect of these medicines taken by the mouth and 
thus introduced into the circulation. In the next section they will be 
treated as acting on the capillary vessels. In this place it must suffice 
to observe, that catalytic medicines have been distributed into no less 
than eight sub-classes, according as they have the power of counteract- 
ing inflammation, neutralising or destroying the poison of syphilis, pro- 
moting the absorption and dissipation of scrofulous deposits, correcting 
the state of the fluids in gout and acute rheumatism, curing scurvy, 
curing ague and other intermittent disorders, curing convulsive maladies, 
and proving more or less beneficial in diseases of the skin. (See Headland 
on the Action of Medicines.) 

3. MEDICINES WHICH ACT ON THE ORGANS OF CIRCULATION. 

1004. We recognise four distinct states of circulation in healthy per- 
sons, in disease, and under the operation of medicines, of which states 
the character of the pulse affords the best indication. 1. Increased fre- 
quency of pulse with increased force and fulness ; 2. Increased frequency 
with diminished force and fulness ; 3. Diminished frequency with in- 
creased force and fulness; 4. Diminished frequency with diminished 
force and fulness. 

1005. In health, the first state of circulation is brought about by 
violent exercise, by spirituous liquors, and by other stimulants; the second, 
by those strong mental emotions and impressions which, in excess, give 
rise to syncope ; the third attends exhaustion and sleep ; and the fourth 
is commonly observed in the less healthy inhabitants of large towns, and 
in those who lead sedentary lives. 

1006. In disease, the first state is present in acute inflammation or 
high inflammatory fever ; the second, in diseases attended with extreme 
debility ; the third, in some cases of hysteria, and in some cases and 
certain stages of apoplexy ; and the fourth, in persons predisposed to, 
but not actually suffering from, pulmonary consumption, as well as in 
those who are recovering from fever, diphtheria, and other exhausting 



238 ge:st:ral therapeutics. 

maladies,, and exceptionally in some epidemics of fever and of the febrile 
exanthemata. 

1007. The same conditions follow the operation of remedies ; the 
frequent, full, and strong pulse is produced by spirituous liquors, by 
ammonia, and by other diffusible stimulants ; the frequent, small, and 
weak pulse by tartar-emetic, tobacco, lobelia inflata, and aconite ; and 
the infrequent pulse, of varying size and force, by opium, digitalis, co- 
nium, stramonium, and other allied remedies. 

1008. In the cases specified — that is to say, in health, in disease, and 
under the operation of remedies — supposing the several states to be pro- 
duced in the same person, with the same quantity of circulating fluid 
in his body, it is obvious that in a given time more blood will traverse 
each organ in the first ease ; less in the second ; a variable quantity, 
sometimes more, sometimes less, in the third ; and a smaller quantity in 
the fourth case. 

1009. In the first case, the quantity of blood traversing each organ 
is increased in two ways ; by the greater frequency of the heart's beat, 
and the larger quantity of blood sent out at each beat ; in the second 
case, the blood traversing each organ is diminished, because the quantity 
sent out from the heart is lessened more than the number of beats is 
increased ; and in the third and fourth cases, the heart sends out in the 
one more, in the other less, blood than will compensate the diminished 
number of its beats. 

1010. The remedies which augment the frequency as well as the 
force of the heart's contractions are called stimulants ; those which aug- 
ment their frequency and diminish their force are called depressants ; 
those which produce diminished frequency with increased or diminished 
force are termed respectively narcotics and sedatives. 

1011. Stimulants (incitants or excitants). — The state of the circu- 
lation, as indicated by the pulse, being made the test and measure of 
the effect of remedies, those are stimulants which increase the frequency 
and force of the heart's contractions. In exceptional cases, however, 
stimulants lessen, in lieu of increasing, the number. 

1012. This excited state of circulation is brought about by the agency 
of the nervous system, whatever the part to which the stimulant is 
applied ; the change in the nervous centres being reflected back on the 
heart and organs of circulation. If, for instance, such a stimulant as 
brandy be taken into the stomach, the impression on its nerves is cou- 
veved direct to the heart through the branches of the solar plexus, or 
to the brain and spinal cord, whence it is reflected upon the heart ; or 
being absorbed into the circulation, it may he applied directly to the 
nervous centres, or to the nerves supplying the lining membrane of the 
heart itself. Here there are many possible ways in which the circula- 
tion may he affected ; but a more simple case is that of exercise, the 
most powerful stimulant of the healthy frame. Its effect on the circu- 
lation is partly mechanical, but it also arises, in part, from the reflection 



USE OF STIMULANTS. 239 

of nervous influence on the heart in common with the voluntary mus- 
cles. Again, the effect of heat applied to the skin, though partly due 
to determination of blood to the surface, depends in some degree on the 
excited state of the nervous system. 

1013. The local effects of stimulants on the healthy body are due 
to the increased flow of blood to all its organs. The rapid and abundant 
circulation through the lungs leads to a more frequent respiration, and 
a more complete decarbonization of the blood : the increased flow of 
arterial blood to the brain excites all its functions ; the impressions on 
the senses are more acute, the flow of ideas more rapid, volition stronger 
and more prompt, the passions excite! , the feelings joyous : the capillary 
circulation is increased ; and the glandular structures pour forth their 
secretions ; the involuntary muscles, too, partake of the general excite- 
ment, and the functions of digestion and defalcation are performed with 
increased vigour. 

1014. But stimulants in excess act as depressants or narcotics. Thus 
spirituous liquors, in large doses, give rise either to collapse or to nar- 
cotism ; in other words, they occasion vomiting, extreme debility, a 
cold sweat, a frequent and small pulse ; or symptoms of apoplexy, with 
oppression of all the functions, paralysis of the voluntary muscles, a slow. 
or a quick, full, bounding pulse. The first effect is commonly produced 
in persons unused to the action of the stimulant ; the second, in those 
accustomed to it. Similar effects are produced by chloroform and the 
aethers : but with them, narcotism is the rule and collapse the excep- 
tion. The action of ammonia is more purely stimulaut than that of 
either alcohol or aether. 

1015. It was stated (§ 1011) that increased frequency, fulness, and 
force of pulse is the test of the action of stimulants, but that there is 
one case in which the test fails. It is the case of debility, without local 
disease, characterised by a small and frequent pulse which loses fre- 
quency and gains force under the use of stimulants. It has also been 
stated (§ 445), that the effect of stimulants on the infrequent pulse of 
debility without local disease, is much less than that produced on the 
pulse in health, — a fact easily explained by the nervous exhaustion that 
attends debility, and renders it dead to all impressions from within or 
from without. If stimulants administered in this state lower the pulse, 
they act favourably as tonics ; if they raise it much, they do harm, im- 
parting momentary strength, to be followed by proportional depression. 

1016. As the question whether we shall or shall not administer 
stimulants in certain diseased conditions is a very important one, it may 
be well to describe the signs which indicate the expediency or necessity 
of resorting to them, as well as those which prove that we were justi- 
fied in administering them. The conditions of systems which especially 
demand the exhibition of stimulants, are, 1. The fainting state. 2, 
The continuous exhaustion brought on by loss of blood, profuse dis- 
charges, prolonged abstinence, an innutritious diet, and mental or bodily 
fatigue. 3. The exhaustion which occurs when febrile disorders assume 



240 GENERAL THERAPEUTICS. 

the typhous or adynamic type : and 4. The exhaustion thac usners in 
many severe diseases. 

(1.) The fainting state, whether produced by sudden loss of blood, by 
violent or prolonged exertion, by exposure to a hot and impure atmo- 
sphere, by intense mental emotion, by the cessation of the heart's action 
in organic diseases of that organ, or by large doses of poisons, such as 
prossic acid, and the vapour of aether and chloroform, demands the 
same treatment ; namely, the shock of cold water, and the diffusible 
stimulants, hartshorn, brandy, &c. 

2- The exhaustion brought on by loss of blood, by continuous pro- 
fuse discharges, or by any of the several causes just specified — a state 
indicated by extreme pallor of the face, skin, gums, and tongue ; small, 
quick, and frequent, or small, frequent, and irregular pulse ; hurried 
respiration, with frequent sighing ; great nervous irritability ; and, in 
some cases, delirium — demands the continued and persevering u^e of 
those less diffusible stimulants which combine alcohol in variable pro- 
portion with a certain quantity of nourishment, such as porter, ale, wine, 
and brandy. The quantity, strength, and repetition of the stimulant 
must be proportioned to the degree of exhaustion. It is generally ex- 
pedient to combine a narcotic with the stimulant, and laudanum is the 
one obviously indicated. 

: . The exhaustion which attends the typhous or adynamic type of 
fevers and inflammations also requires the use of stimulants. In the ex- 
treme degree of this state, marked by the position on the back, the sink- 
ing of the body towards the foot of the bed, the picking of the bed- 
clothes, the low muttering delirium, and the involuntary discharges, such 
remedies are obviously necessary. But long anterior to this stage of ex- 
treme exhaustion and collapse stimulants may be given with the : : 
advantage, though some of the symptoms may be such as to - 
doubt of the propriety of administering them : the skin may be hot and 
dry, the tongue coated with a d:y fur, the breathing quickened, the pulse 
frequent and sharp with some fulness, the countenance dusky, the vessels 
of the eye injected with dark blood, the patient restless and delirious, his 
movements indicating considerable muscular strength. In this state of 
things it may become a grave practical question whether stimulants 
ought or ought not to be given, and our doubts can only be decided by 
actual experiment, and careful observation of the patient before and after 
the use of the stimulant. The best mode of procedure is first to examine 
and count the pulse ; then, having caused the patient to swallow a glass 
of wine, to examine and count it afresh. If it become more frequent, 
and increase in hardness and sharpness, the stimulus is unsuitable ; but 
if it fall and become decidedly slower and softer, we were justified in the 
use of the stimulant, and may repeat it. li, after an interval of a few 
hours, during which we have pei severed in the use of stimulants, we 
find the puise less frequent, slower, and softer, the tongue becoming 
moist, the skin cooler and moistened with perspiration, the breathing 
deeper and slower, the countenance less dusky, the eye more clear, and 
the restlessness and delirium abated, we have every reason to persevere 



TONICS — DEPRESSANTS. 241 

in this course of treatment. A sign much insisted on by Dr. Stokes, as 
decisive of the necessity for stimulants, is the state of the heart. As it 
partakes of the weakness which affects the entiie muscular system, its 
pulsations become extiemely feeble, and the first sound almost imper- 
ceptible. The beneficial operation of stimulants is therefore indicated 
by a stronger impulse, and renewed distinctness of sound. As the one 
condition indicates the necessity for stimuli, so does the other justify 
their use. 

(4.) The exhaustion which commonly supervenes in the advanced 
stages of continued fever, and in other diseases which have put on the 
typhous type, is sometimes present in the early stages of the same 
maladies. The first effect of the poison of the several infectious and con- 
tagious disorders is sometimes nearly allied to collapse. The patient is 
extremely weak, and faints on the slightest exertion, the countenance is 
pale, the surface cold, the pulse frequent, full, quick, and extremely 
compressible, and the respiration hurried. In this state also it may be 
a question whether stimulants ought to be employed, and actual experi- 
ment alone can decide the question. If the stimulant lowers the pulse 
and renders the breathing less frequent, we are justified in prescribing 
its repetition, taking caie, at the same time, to be on the watch for the 
reaction which in most cases follows this state of depression. 

1017. Tonics. — These remedies, as the name implies, are given in 
states of debility, and specially in convalescence from exhausting mala- 
dies, with a view of restoring firmness, strength, and tone to the entire 
frame. In extreme weakness, stimulants impart real strength ; in other 
words, they become tonics. In less degrees of debility, they produce less 
obvious effect than on the robust and healthy. Again, stimulants in 
large doses become tonics in small ones. But the class of remedies to 
which the term tonics is commonly and properly applied gradually re- 
store the strength without stimulating the system. One class of tonics, 
the preparations of iron, owes its virtues to its power of supplying a 
deficient element of the blood. The good effects of other tonics (such 
as bark, and its active principle quina) are not so readily explained. 

1018. Depressants. — This name distinguishes a class of remedies 
which render the pulse frequent, small, and weak, being the exact re- 
verse of the action of stimulants. This change in the circulation is 
accompanied by great prostration of strength, nausea, cold sweats, and 
all those symptoms which characterise approaching syncope ; and it is 
brought about by the abstraction of blood, by the preparations of anti- 
mony, by tobacco, aconite, and the lobelia intiata, and by the less active 
remedies, ipecacuanha and squills. 

1019. The loss of a large quantity of blood, or the rapid removal of 
a smaller quantity, occasions syncope, or a state approaching it ; and as 
during this state the heart sends out a comparatively small quantity of 
blood, and propels it with little force, that part of inflammation which 
is due to increased action of the heart is removed by blood-letting. 

1020. Tartar- emetic, which, next to bleeding, is our sheet-anchor in 

R 



242 GENERAL THERAPEUTICS. 

acute inflammation, and is the only depressant of acknowledged power 
and efficacy which acts simply as a depressant, brings about the same 
state as is produced by bleeding, and may be employed either alone or 
in combination with it in the treatment of all acute inflammations. 

1021. As there is an exception to the rule that stimulants increase 
the number and force of the pulse, so is there an exception to the rule 
that denressants increase its number while they lessen its force. Thus 
blood-letting, which belongs to the order of depressants, renders the 
pulse full and strong, and even increases its frequency, in certain cases 
of plethora, when the circulation is oppressed, and in pneumonia, when 
the pulmonary circulation is impeded. Again, in cases of acute inflam- 
mation with high inflammatory fever, bleeding or tartar-emetic will 
lessen the frequency and force of the pulse at the same time. In all 
these cases, the modus operandi is the same ; it appears to be different 
only because the circumstances vary. 

1022. Sedatives. — These remedies differ from stimulants and depres- 
sants, inasmuch as, in lieu of increasing the frequency of the pulse/ they 
diminish it. The true sedatives differ from the pure narcotics inasmuch 
as in large doses they cause delirium, while the narcotics in large doses 
occasion coma and apoplexy. Sleep, also, is an occasional, not a con- 
stant, effect of sedatives. 

1023. Hydrocyanic acid, digitalis, and aconite, the principal reme- 
dies of this class, commonly lower the pulse. But there are states of 
system in which these remedies increase its frequency, just as there are 
states in wiiich the effect of stimulants and depressants on the circulation is 
reversed. Digitalis, for example, which, in diseases accompanied by a 
frequent pulse., low T ers it in a remarkable degree, and often much below 
the healthy standard, in some healthy persons, and perhaps in all, has 
the reverse action.* The effects of hydrocyanic acid are more constant ; 
but exceptions doubtless exist to the rule of its operation. 

1024. Cold is a most powerful sedative. A moderate degree of cold 
applied to the surface acts as a stimulant ; but when the skin is hot and 
dry it reduces the temperature, lowers the circulation, soothes the ner- 
vous system, and disposes to sleep. Applied to the head, in the form of 
cold lotion or of ice, it is a most valuable remedy in inflammatory affec- 
tions of the brain ; and it is of the greatest service in all inflammations and 
haemorrhages. Ice may be swallowed with advantage in bad cases of 
quinsey and scarlatina, and in hydrophobia with great relief to the symp- 
toms. Applied locally, in the form of douche, it restores the contrac- 
tility of the capillary vessels, and by preventing further effusion, allows 
the absorbents to remove any fluid that may have been thrown out. In- 
tense cold is also a valuable anaesthetic, and has been lately employed by 
Dr. Richardson (as aether spray) in painful operations on superficial parts. 

* See the experiments of Dr. Saunders on his own person, detailed in his work 
on Consumption. 



TEEATMENT OF INFLAMMATION. 243 

It also acts as a narcotic, and may produce states of system difficult to 
distinguish from the effects of alcohol. 

1025. Narcotics. — The action of these remedies belongs so completely 
to the fourth head (the action of remedies on the nervous system) that 
nothing need be said in this place except that their effect on the circula- 
tion is the opposite of that produced by stimulants and depressants. 
They lessen the frequency of the heart's contractions. They also affect 
the respirations in a striking manner, diminishing their number in a 
still greater degree than that of the pulse. 

1026. The remedies which have just been examined affect the circu- 
lation primarily by their influence on the nervous centres ; and second- 
arily, through the reflection of that influence on the heart. It remains 
to speak of the remedies which affect the smaller vessels. 

1027. Remedies which affect the Small Vessels ; Treatment of inflam- 
mation. — It has been already stated that in inflammation there is dimin- 
ished action (that is, diminished contractility) of the small arteries, with 
increased action of the heart, and that the two together keep up that 
dilated state of the small vessels which is the essence of inflammation. 
It is obvious that there are two ways in which these minute vessels may 
be restored to their healthy state : the first is by lessening the quantity 
of blood passing through them ; the second, by increasing their con- 
tractility. In most acute inflammations, both changes have to be 
brought about. If the inflammation be recent, the small vessels may 
recover themselves on being relieved from the undue quantity of blood 
sent to them by the heart ; and in this case the abstraction of blood, or 
the use of depressing remedies, will suffice. But if the inflammation be 
chronic, the small vessels may not recover their contractility, though the 
blood circulates through them in diminished quantity ; and in this case 
we must use such remedies as restore the lost contractility of the vessels. 
The same treatment is required in the analogous state of congestion. 

1028. The treatment of inflammation then is twofold — it consists in 
lessening the quantity of blood sent out by the heart on the one hand, 
and in restoring the lost contractility of the small vessels on the other. 
The first indication can be fulfilled only by general remedies, the second 
by geneial or by local means. 

1029. As the increased action of the heart occurs only in the acute 
form of inflammation, it is in that form alone that general remedies are 
necessary. These remedies are blood-letting, aided, in certain cases, by 
active purgatives ; and depressants, of w 7 hich the best is tartar- emetic. 
An acute case of pleurisy occurring in a robust man, or in one previously 
enjoying good health, would be appropriately treated by bleeding to the 
approach of fainting, or the complete cessation of pain, followed at once 
by tartar-emetic, in such doses and at such intervals as to keep up a 
constant state of nausea. Bleeding alone, even though often repeated, 
would not subdue the inflammation, for it is followed by reaction, and 
that reaction re-establishes the inflammation. By combining depletion 
with depressing remedies we save blood, and avert chronic disease. 



244 GENERAL THERAPEUTICS. 

1030. But it should be understood that the prompt and decisive 
treatment of acute inflammation in healthy persons does not admit of 
extension to the so-called inflammations of the unhealthy inhabitants of 
large towns, in whom it may be necessary not merely to abstain from 
depletion, and the use of depressing remedies, but even to adopt an oppo- 
site mode of treatment. 

There is also one disease of common occurrence, and fatal tendency, to 
which, for obvious reasons, the active treatment of inflammation is in 
most cases inapplicable. That disease is pneumonia, which is, in part, 
an inflammation affecting the vessels supplying the texture of the lung, 
and in part a congestion of tlie vessels conveying the blood to and from 
the lung for oxidation. The active measures which would subdue in- 
flammation in the tissues of the lung, would, by reducing the force of 
the heart's beat, rather increase than diminish the congestion of the 
pulmonary vessels. In this disease, therefore, a purely expectant treat- 
ment, or, in the case of the inhabitants of large cities, a simulant plan, 
has been shown to produce the best results. 

1031. The strong action of the heart which attends acute inflamma- 
tion is absent in inflammation of the mucous membranes, unless it takes 
on the most acute character, as in croup, or in cases of irritant poison- 
ing. It is absent also in erysipelas, and in many inflammations attack- 
ing persons of broken constitution. The chief inflammatory diseases 
which affect the general circulation are those of the serous membranes 
and acute rheumatism. 

1032. When inflammation of the mucous membranes is very severe, 
especially if the affected membrane line some narrow passage apt to be 
filled with the secretion poured out from its surface, depletion is neces- 
sajy. Thus we bleed in croup, partly on account of the seventy of the 
inflammation, and partly because the narrow passages of the larynx and 
trachea aie apt to be filled up by tenacious secretion. 

1033. When the seat of inflammation is an organ of extreme delicacy? 
we are obliged to employ general remedies, though the disease does not 
affect the circulation or threaten life. Thus, in inflammation of the in- 
ternal parts of the eye, the most active measures are necessary to save 
the organ from destruction. 

1034. As a general rule, then, it may be stated, that blood-letting is 
required in inflammation attacking robust and plethoric persons, or when 
it is attended by increased action of the heart, or when some function 
essential to life is impeded, or some delicate organ threatened with de- 
struction. 

1035. The second indication — that of causing contraction of the small 
vessels — may be accomplished in various ways : locally, by pressure, cold, 
astringent applications, and the cautious use of substances which them- 
selves cause inflammation, but act as stimulants when applied in small 
quantity, and tor a short period; and generally, by remedies which 
experience has shown to possess that pioperty. 

1036. If the vessels are much distended, local depletion is indicated 



I 



TBEATMENT OF H^HOBEHAGE. 245 

as a preparatory measure. When the small vessels have by this means 
been partially emptied, we may apply the remedies just mentioned ac- 
cording to the nature of the inflamed part. Pressure, properly applied, 
lends support to the vessels ; cold acts on all the textures of the part, on 
its vessels as well as on its nerves; astringent applications cause all the 
textures to contract, at the same time that they gently irritate the vessels, 
and excite them to the performance of their proper function ; while such 
irritants as nitrate of silver, and sulphate of zinc or copper, prove bene- 
ficial by their stimulating property. 

1037. All these applications are used with advantage — pressure in 
chronic inflammation and ulceration of the extremities, and in swelled 
testicle ; cold, in every form of external and internal inflammation, in 
the inflammatory sore throat of scarlatina maligna, in the inflammation 
of the fauces attending hydrophobia, in inflammatory diseases of the 
rectum and vagina ; astringents, in common or specific inflammation of 
the mucous membranes ; stimulants in inflammation of the skin, in 
irritable ulcers, and in inflammation of the mucous membranes. 

1038. The general remedies which promote the contraction of the 
small vessels (that is to say, remedies which act through the system and 
not by local application), are the metals, especially tartar-emetic, mer- 
cury, and arsenic, iodine, and, in a less degree, the fixed alkalies, and 
their salts. There are also certain remedies which affect particular 
organs, as uva ursi, copaiba, cubebs, pepper, cantharides, and turpentine. 

1039. The first class of remedies (tartar-emetic, mercury, arsenic, and 
iodine), when applied to the skin, excite inflammation, thus showing the 
power which they exercise over the small vessels. They may also be 
absorbed and circulated with the blood so as to be applied to these vessels 
in the most direct manner; thus exerting the same power of curing 
inflammation which nitrate of silver has when locally applied. 

1040. The cases in which one of these remedies is more applicable 
than another are found out empirically. Tartar-emetic is to be pre- 
ferred in common, mercury and iodine in specific, inflammation. Mer- 
cury is to be preferred in cases of great urgency (such as iritis and 
croup), when our object is not merely to subdue inflammation, but to 
suspend the specific disease of which it is a part. 

1041. Uva ursi, copaiba, cubebs, and black pepper are employed with 
advantage in inflammation of the mucous membiane of the urinary pas- 
sages. They act as direct stimulants through the urine, and when given 
in sufficient doses, cure gonorrhoea, even in its acute stage. Uva ursi 
is used chiefly in inflammation of the mucous membrane of the bladder ; 
copaiba and cubebs in gonorrhoea (in which disease pepper has also been 
employed), and black pepper in haemorrhoids. Copaiba has been pre- 
scribed with advantage in cases of bronchitis. 

1042. Hozmorrliage. — Active haemorrhage demands the same reme- 
dies as acute inflammation ; and passive haemorrhage those which are 



246 GENERAL THERAPEUTICS. 

useful in some forms of chronic inflammation — viz., cold, the prepara- 
tions of lead, and medicines which contain tannin. 

1043. The treatment of febrile affections is governed by the same 
general principles as the treatment of inflammation. When free from 
the complication of local disease, and attended by a frequent, full, and hard 
pulse, depressing remedies, such as bleeding and tartar-emetic, separate or 
combined, are indicated : but in cases attended by great prostration, with 
a small and frequent pulse, tonics or stimulants, according to the degree 
of debility. Local disease must be treated by general or local remedies, 
according to the powers of the system, with the precaution that the 
patient's strength must be husbanded, in order that he may not be 
worn out before the disease has run its appointed course. The same 
remark applies to those febrile affections of which local inflammations 
form a constituent part, as measles, scarlatina, small-pox, and erysipelas. 

1044. The process of secretion is one over which medicine exerts 
much power, directly and indirectly. The most important secretions 
are those of the lungs, skin, kidneys, and bowels. The aerial secretions 
of the lungs are not subjects of observation or measurement. 

1045. The influence of remedies on the secretions will be best under- 
stood by selecting that of the skin as an example. When the skin is red, 
hot, and dry, we can excite perspiration by the application of cold ; when 
it is pale, cold, and dry, by heat. In the one case, we diminish the size 
of the small vessels, and lessen the quantity of blood they contain ; in 
the other, we increase both. In the same conditions of skin, and in the 
same states of system, we produce the same results by depressants and 
stimulants, so that, in the case of this secretion, we can produce the same 
effect by a local application and by an internal remedy. In both cases, 
the temperature favourable to sweating is intermediate between the two 
opposite conditions accompanied by the dry skin ; and may be termed 
the " sweating point." 

1046. This point is not fixed, but varies in different persons, not only 
with the temperature of the skin and the quantity of blood circulating 
through the vessels, but with the condition of the vessels themselves ; 
so that in strong and robust persons it must be much higher than in those 
worn out by disease ; while in extreme debility it is well known that 
cold sweats take place from mere relaxation of the vessels, when the 
temperature of the body is extremely low. 

1047. The fact that increased secretion from the skin may be brought 
about by remedies which act on the general circulation, may be extended 
by analogy to other secretions also. Thus, blood-letting, practised in a 
case of inflammatory fever, will promote the flow of all the secretions, 
by relieving the congestion of the vessels, and so bringing the glands to 
what may be termed their secreting point. 

1048. When, therefore, we wish to promote the secretions, and espe- 
cially that from the skin, we strive to bring the circulation into that 
state in which secretion is possible. When the skin is hot and dry, we 



REMOVAL OF SOLID TEXTURES. 247 

select a depressant, when cold, a stimulant, diaphoretic ; and we select 
a stimulating diuretic in languid states of circulation, a depressing one 
when there is strong febrile action. 

1049. It is not meant to assert that all remedies which promote se- 
cretion act only through the general circulation ; for the strong analogy 
which may be drawn from the local action of remedies on the small 
vessels in inflammation must admit of application to other states of those 
vessels. Tartar-emetic, for instance, combines a stimulant local action 
with a depressing effect on the general circulation. 

1050. There is, indeed, one case in which the action of remedies in 
promoting secretion appears to depend almost exclusively on their adap- 
tation to the quality of the secretion itself. The urine, for instance, 
abounds in salts, and saline medicines are of great efficacy in promoting 
that secretion : the perspiration, too, contains salts, though in less quan- 
tity, and may, therefore, be increased by remedies of which salines form 
a part. Thus, Dover's powder may possibly derive part of its efficacy 
from the sulphate of potash which it contains. 

1051. The remedies which promote the absorption of fluids thrown 
out into the cavities of the body, act for the most part through the 
general system. Of these the most powerful is blood-letting, which 
acts by diminishing the quantity of the circulating fluid, and when the 
cause of dropsy is inflammatory, by removing the inflammation. The 
other remedies in common use are employed with the same views. They 
are directed to the secreting organs, the bowels, kidneys, and skin. 
The increased secretion from these parts has the twofold effect of blood- 
letting — it lessens the quantity of the circulating fluid, and it subdues 
inflammation. 

1052. When the patient is very weak, tonics or stimulants (for sti- 
mulants are tonics to the weak) may have to be combined with depletion. 

1053. The local means best adapted to promote absorption, are those 
which act as stimulants to the parts affected, such as friction with the 
hand, or with stimulating liniments, tincture of iodine, a jet of cold 
water, or electricity. These agents act favourably either by restoring 
the capillaries to their healthy state, or by stimulating the absorbents. 
(See § 341.) 

4. REMEDIES ADAPTED TO THE REMOVAL OF THE SOLID 
STRUCTURES OF THE BODY. 



1054. Morbid growths have been divided (see § 381) into < 
and heterologous. Experience shows that we have little or no power 
over the latter class ; they form one of the opprobria of medicine, and 
where they cannot be removed by the knife, we can do little more than 
alleviate the sufferings they occasion. Analogous formations which do 
not consist in mere hypertrophy of a natural texture, are also little 
amenable to treatment. 



248 GENERAL THERAPEUTICS. 

1055. Atrophy and hypertrophy, indeed, seem to be the only altera- 
tions of the solid structures which are under the control of medicine. 
The remedies applicable to a state of atrophy are, exercise, friction, elec- 
tricity, and, in short, all those means which increase the flow of blood 
to the part and promote its natural actions. Those, on the other hand, 
which are of use in hypertrophy are, rest, pressure, cold 5 local abstrac- 
tion of blood, and preparations of mercury and iodine. 

5. REMEDIES WHICH ACT OX THE XERVOUS SYSTEM. 

1056. As all the functions of the body are more or less dependent on 
nervous influence, all active remedies must affect the nervous system. 
Stimulants, depressants, sedatives, narcotics, and some medicines, at least, 
which belong to the class of tonics, affect the circulation through the 
nerves ; and even those remedies of which the action is strictly local act 
locally on the nerves, and, through them, on the vessels to which they 
are distributed. But there are some substances which exert so peculiar 
an influence on the nervous system as to demand a separate notice. In 
this action we recognise three marked varieties. Some produce a state 
of excitement in all the functions of the nervous system ; others soothe 
the nerves, tranquillise the mind, and procure sleep ; while a third class 
act chiefly on the organs of circulation and respiration, while they derange 
the functions of the brain, and occasion delirium. The first class are 
known as stimulants, the second as narcotics, the third as sedatives, 

1057. (1.) Stimulants. — The mode in which these remedies affect the 
body, and the cases in which they may be used with advantage, have 
already been pointed out (§ 1011). But they not only affect the cir- 
culation in the manner described, but also all the functions of the brain, 
spinal cord, and nerves. The most active and efficient stimulants are 
ammonia, and its carbonate, phosphorus, musk, mustard, and turpen- 
tine ; to which may be added the more active and diffusible among the 
narcotic medicines, alcohol, aether and chloroform, and camphor, the first 
effect of which is to stimulate the system. To these may be added, as 
special stimulants to the spinal cord and nerves of voluntary motion, the 
alkaloids strychnia and brucia, and the plants that contain them. 

1058. (2.) Narcotics. — The narcotics, of which opium, and its alka- 
loid, morphia, are the chief, and lactucarium, the hop, and the nutmeg, 
the less important, are used to relieve pain (anodynes) ; to soothe irrita- 
tion (^paregorics) ; to diminish inordinate muscular contraction (anti- 
spasmodics) ; or, lastly, to procure sleep [hypnotics, or soporifics). 
Opium is both stimulant and narcotic ; hence it is admirably adapted 
to the state of irritation accompanied by much debility, the narcotic 
principle soothing the excitement, the stimulant counteracting the de- 
bility. Sulphuretted hydrogen, carbonic acid, carbonic oxide, and cy- 
anogen gas, act also as narcotics. As such carbonic acid gas has been 
locally applied. 

1059. The remedies which occasion sleep or stupor as their leading 
symptom are sometimes grouped under the one head of narcotics, which 



SEDATIVES. 249 

is then subdivided into the smaller groups ot inehriants, soporifics, and 
deliriants. The first group (inebriants) comprises alcohol and alcoholic 
liquors, chloroform and the aethers, camphor, and the Indian hemp, to 
which are sometimes added tobacco and lobelia inflata. All these re- 
medies produce the phenomena of intoxication ; but while the first-named 
act first as stimulants, the last two, tobacco and lobelia, have the oppo- 
site effect of depressants. The second group (soporifics) contains only 
one medicine of importance, opium ; lettuce, hops, and nutmeg being of 
inferior value, and therefore rarely used. The third group ( deliriants) 
comprises hyoscyamus, belladonna, and stramonium ; which, it is 
scarcely necessary to observe, are not given in the practice of medicine 
in such doses as to cause delirium. As medicines they rank with seda- 
tives. Of these three groups the first and second are the most impor- 
tant ; the first as containing the invaluable anaesthetic chloroform ; the 
second, the no less valuable drug, opium. 

1060. (3.) Sedatives. — This class comprises many substances allied 
in some of their properties to the narcotics, and in others to the depres- 
sants. They differ from the narcotics in not producing sleep, but, on the 
contrary, delirium. Thus, hyoscyamus, belladonna, stramonium, monks- 
hood, black hellebore, veratria, colchicum, and camphor, to which, per- 
haps, musk and valerian may be added, give rise to delirium in the first 
instance, sometimes followed, after a considerable interval, by coma. 
Tobacco, ipecacuanha, conium, squills, and digitalis, appear to produce 
coma without previous delirium. Tobacco, ipecacuanha, and squills, and 
the lobelia inflata, have been already described as depressants, and have 
been shown to have a remarkable effect on the muscular system. Tea 
and coffee belong to the class of sedatives. But this class contains no 
more important member than cold. 

1061. Cold has already been mentioned more than once, when speak- 
ing of the effect of medicines on the circulation, as a remedy of great 
power (§ 1024). But cold may produce a marked sedative effect on the 
nervous system, without any corresponding effect on the circulating 
organs. It blunts sensibility and subdues pain, and in cases of violent 
nervous excitement it allays the irritation of the nervous system, reduces 
the number of the pulse, subdues the most violent pain, and infallibly 
procures sleep. It is also of great efficacy in the most violent paroxysms 
of mania. 

Having indicated the chief remedies which affect the nervous system, 
it will be useful to speak more particularly of their action on the special 
functions of sensation and voluntary motion. 

1062. The remedies which act on the nerves of sensation are classed by 
the toxicologist with narcotic or narcotico-acrid substances ; but in works 
on Materia Medica they are considered as sedatives. Of these aconite is the 
most powerful. It produces numbness, and a tingling sensation in the 
parts to which it is applied. Strong hydrocyanic acid, locally applied, 
also causes numbness ; opium and belladonna, too, act locally on the 
nerves of sensation ; and chloroform acts as a powerful local anaesthetic, 



250 GENERAL THERAPEUTICS. 

after producing, as its first effect, redness and heat of surface. But the 
best sedative is cold. It is sure and manageable, and, with proper pre- 
cautions, may be applied whenever a sedative is indicated. 

1063. Belladonna shares with hvoscyamus and stramonium the power 
of dilating the pupil through its action on the retina, whether given in- 
ternally or applied directly to or near the eye. The Calabar bean has 
the opposite effect. 

1064. The nerves of voluntary motion, and through them the mus- 
cular system, are powerfully affected by lemedies in three different ways 
— with paralysis, convulsions, and tonic spasms. 

1065. Extreme muscular debility is the familiar effect of all depress- 
ing remedies, and especially of tobacco. The same effect is produced by 
tartar-emetic among mineral, and tobacco and lobelia intiata among 
vegetable, poisons. Paralysis, or the extreme of muscular weakness, is 
produced by various poisons, as the woorara, ticunas, and curare, and 
by large doses of aconite and conium, and by one metallic poison — lead. 

1066. Convulsions are produced by almost all active poisons. They 
precede the fatal event in quick poisoning by hydrocyanic acid. They 
occasionally occur in poisoning by opium, arsenic, and the more active 
mineral poisons. 

1067. Tetanic spasms are produced by nux vomica, by St. Ignatius 
bean, by the upas tieute, and by the active principles strychnia and 
brucia. They are an occasional effect of monkshood, and of the ergot 
of rye taken in poisonous doses, and they are sometimes present in poi- 
soning by the more active irritants. 

1068. The muscular contractions of the uterus caused by the secale 
cornutum furnish an example of local action on the muscular fibres, of 

which advantage is taken in the practice of midwifery. 

1069. The treatment of diseases dependent on, or accompanied by, 
local affections, with reflex action of the muscles, is of much importance, 
especially in such diseases as tetanus and hydrophobia. In the latter 
disease ice has been swallowed with great relief to the symptoms. 

1070. Many of the metallic substances used in medicine, such as the 
salts of arsenic, copper, iron, silver, and zinc, appear to exert a peculiar in- 
fluence on the nervous system. They act locally as irritants, and when 
administered in small doses, and during a considerable period, as tonics ; 
as such, they have been used with advantage in chorea and epilepsy. 

6. NURSING. 

1071. In nursing, attention must be given to the following particu- 
lars : — Situation of the sick-room ; the room itself — its arrangements, 
temperature, ventilation, light, refreshment ; administration of medicine 
and food ; general condition and personal comfort of the patient ; his in- 



XTTKSING. 251 

tercourse "with his attendants ; precautions to be used in cases of con- 
tagious disease. 

1072. Situation of the Sick Boom. — When we can exercise a choice, 
a south, south-west, or west aspect should be preferred, in acute in- 
flammation of the brain or eye a north aspect is best. 

The room should be spacious, lofty, lightsome, and furnished with a 
chimney having a good draught. In some cases the carpet may be retained, 
but all superfluous furniture, hangings, and articles of clothing should 
be removed. 

1073. The patient's led should be placed with its head out of direct 
currents of air from the door and windows, and with ready access to 
either side of it. It should be furnished with rollers that it may be 
wheeled to any part of the room. As a rule it should be without curtains. 
A calico screen may be used to intercept draughts, or the view of the 
door, and of the part of the room used by the nurse in preparing food 
or medicine. 

1074. Temperature, — This may range from 60° to 70° Fahr., accord- 
ing to the feelings of the patient, and should be kept as constant as pos- 
sible. If the patient complain of cold, a hot water bottle, or cushion, or 
an additional blanket may be used. 

1075. Ventilation. — In cold and moderately warm weather a fire 
should be kept constantly burning. If the external air be very cold, the 
fresh air may be derived through the dpor from the lower parts of the 
house ; if temperate, the landing window and the bedroom door, or one 
of the bedroom windows, should be opened. In summer, when it is too 
warm to have a tire, the windows should be wide open during the day 
and at night be partially opened. The door maybe kept ajar and occa- 
sionally fanned to and fro to cause a freer circulation of air. Vitiation 
of the atmosphere of the sick-room by many visitors and too many at- 
tendants must be avoided. The combustion of gas, too, must be prohi- 
bited. Growing plants may be freely introduced into the sick-room, as 
they serve both to purify and to moisten its atmosphere. 

1076. Light should be moderated according to the feelings of the 
patient. If he be watchful it should occasionally be excluded during the 
day, advantage being taken of the times when the vigilance is least. It 
must be constantly excluded in cases of active inflammation of the brain 
or eye. Direct sunlight is rarely tolerated in acute disease, but in some 
chronic diseases it is both pleasing and refreshing. 

1077. Refreshment. — Offensive odours diffused through the air may 
be counteracted by burning incense or a pastille, sprinkling eau de Cologne, 
or burning coarse brown paper saturated with a strong solution of nitrate 
of potash, dried, and kept for use. But for their more effectual removal 
the carpet should be taken up, the floor sprinkled several times a day 
with solution of chloride of lime ; or rags wetted with Condy's fluid 
(solution of permanganate of potash) should be suspended near the bed. 
In cases of infectious disease, such as fever, diphtheria, gangrene of the 



252 GEXEKAL THERAPEUTICS. 

lungs, &c, baskets of wood charcoal should be placed under the bed and 
in the corners of the room, and the evacuations should be received into 
a solution of chloride of lime, zinc, sulphate of iron, or permanganate of 
potash ; or into a mixture of dry earth, ashes, or powdered wood char- 
coal, with sulphate of iron (ftjj to ^ij. 

1078. Administration of Medicine. — Pungent melicines should be 
given well diluted with water, to obviate coughing and nausea. Doses 
should be carefully measured in a medicine-glass, and given without 
delay, especially when they contain volatile ingredients. Deposits, it 
any, should be well shaken up. In the intervals the bottle should be 
kept closely corked. As a rule, medicine should be given an hour before 
food. But if nutriment has to be administered frequently, the medicine 
must be so given as least to interfere with it ; stimulants may be taken 
with stimulants, and tonics with food ; purgatives should be given before 
food ; hypnotics at any time. 

1079. Administration of Food. — If a patient has a distaste for food, 
Tery small quantities should be offered at a time. He may thus be in- 
duced to partake of it again and again when a larger quantity presented 
at once would be rejected. In irritable conditions of the stomach a table- 
spoonful of nourishment may excite vomiting, while a teaspoonful repeated 
often would be retained. Strong tea and jelly may be both suitable and 
harmless, but together, we must remember, they form indigestible leather. 
Orange and grape juice is generally harmless, but few things are moie 
indigestible than the pulp, skins, and seeds of these fruits. In the 
typhous condition food or stimulants are needed every hour ; and as the 
patient is well-nigh insensible to his wants, his life depends on the close 
attention of the nurse. 

1080. The nurse should be quiet, circumspect, and firm, and possess 
the tact only to be acquired by experience. Good eye-sight is indispens- 
able. She should set aside out of reach sedative draughts, liniments, 
and other external applications, keeping within easy reach only such 
mixtures or draughts as are required at short intervals. She should be 
provided with oiled silk, oiled cloth, &c, so as to prevent discomfort in 
the use of poultices and moist applications. She should be allowed as 
little discretion as possible ; written directions as to the nature and quan- 
tity of food and medicine, and the times of its administration, should be 
given to her, and she should be directed to make a written report accord- 
ingly, noting down the number of hours during which the patient has 
slept, the time at which any new symptom, such as pain, dyspnoea, vomit- 
ing, or fits, &c., occurred ; and whether, and when, the bowels or bladder 
have acted. She should be directed in certain cases — such as constipa- 
tion, diarrhoea, enteric fever, dysentery, hepatic disease — to set aside the 
evacuations in the water-closet. In severe disease a bed-pan and glass 
urinal should be provided for the patient's use. The urine should be 
occasionally preserved for examination. 

She should look to the general condition of the patient, and note the 
temperature of the body, and especially of the feet. In the typhous con- 



GENERAL MANAGEMENT OF THE SICK EOOM. 253 

dition these parts may be found cold and purple, when it is too late to 
recover them from this incipient stage of gangrene. In spinal and cerebral 
diseases, as well as in the typhous condition, the integument over the 
sacrum and trochanters must be daily looked to ; and if it appear con- 
gested, lead plasters spread upon amadou or wash-leather must be applied, 
and the pressure obviated by a water- pillow or water-bed. The medical 
attendant must occasionally verify the statements of the nurse, and him- 
self examine the condition of the hypogastric region. When, in cold 
weather, a patient is placed on a water-bed, a thick non-conducting layer 
of folded blankets must be put between the bed and body. If cold be 
complained of, we must occasionally introduce hot water and draw off 
the cold. 

1081. Personal Comfort of the Patient. — If the patient's condition 
allow of it his bed should be made every day, a couch being at hand to 
receive him. In cases of protracted illness two beds may be provided 
with advantage. The linen should be changed as often as it can be done 
without undue fatigue, and advantage should be taken of this change to 
administer a bath, or to sponge the surface with warm water. A bath 
is a very important adjunct to a sick room, for we have no more efficient 
means of provoking sweat and of soothing nervous excitability than the 
warm bath. Jn some cases (scarlatina, suppression of urine, convulsions) 
its use is indispensable. A thermometer should be at hand to regulate 
the temperature. For a tepid bath we may prescribe 85° ; for a warm 
95°; for a hot 105°. 

If it can be done without fatigue, the teeth should be brushed, the 
mouth cleansed occasionally, and the hair brushed. 

1082. Thirst may be allayed by toast-water, thin gruel, or barley- 
water, by soda-water, lemonade, or iced water slightly acidulated, it 
need be, with sulphuric or phosphoric acids, and sweetened. In the 
typhous condition spirit or wine may be added to these drinks. 

1083. General Management of the Sick-room. — All should be quiet 
and yet cheerful here. If the patient be unduly apprehensive, anxious 
looks and tones must be avoided in his presence. When he is awake 
to impressions, there should be no whisperings in his presence or 
hearing. In the sick-room all our communications should be with the 
patient, either directly or openly through the nurse. We must inspire 
confidence and hope by a plain, easy, and decided manner. There must 
be no mystery or ambiguity about our acts and words. We must 
answer the solicitous inquiries of the patient as simply and straightfor- 
wardly as possible, so as to leave no doubt in his mind. " You are 
better by this little indication." " You are worse because of this com- 
plication, against which I am going to direct remedies such as we may 
reasonably hope will cause it to yield sooner or later." "What you 
want is sleep, and this we will secure for you to-night." Such must 
be the language of the medical attendant. 

1084. The sensations and ideas are so perverted in delirium that 
patients labouriug under mental disease, whether primary or secondary, 



254 GENERAL THERAPEUTICS. 

are best treated by assuming a cheerful indifference. When homicidal 
and suicidal tendencies exist, cutting instruments must be removed, and 
windows secured. If the patient obstinately refuse food, do not press 
it — put it from time to time before him, and let others eat in his pre- 
sence. Loud, strange, or uncertain noises should be prevented. The 
influence of musie may be brought to bear in certain cases. 

1085. In protracted illness, when the intellect is clear, we should vary 
the position of the bed, and change from time to time the pictures, 
ornaments, and furniture of the room, and distribute about it Wardian 
cases, aquaria, growing plants, and cut flowers of various hue ; for 
anxiety and gloom are inseparable companions of severe illness, and we 
should not neglect any means, however trifling, of dispelling them. 

1086. When a case of contagious fever occurs in a house, and the 
patient cannot be removed, strict precautions are necessary to prevent 
the spread of the disease. The younger members of the family should 
be sent away at once, or, if this be impracticable, they should live and 
sleep on the ground-floor. The patient should be placed in the airiest 
and most secluded room in the highest part of the house, and only those 
in attendance should have access to that story. If possible, he should 
be under the care of a single nurse, and an adjoining room should be 
devoted to her use, with ready means of communication with the people 
below. Her food and that of the patient should be brought up to the 
landing on the floor below, where she should receive it. She should 
go down stairs as seldom, and keep aloof from other persons as much, as 
possible. Before leaving her room she should be careful to wash her 
hands. A fire and a large kettle of boiling water should be constantly 
at hand. A separate set of articles should be devoted to the patient's 
and the nurse's use, and before they are sent down stairs they should 
be placed in a vessel, and boiling water poured from the kettle upon 
them. Linen should be treated in the same way, and then wrung out 
and put aside. It should be allowed to accumulate to the end of the 
illness, and after a second exposure to the action of boiling water, be 
sent to the laundress. The patient's room must be thoroughly ventilated. 
Disinfectants should always be mixed with the dejections, and they 
should be conveyed to the water-closet in a tightly-covered vessel. The 
water-closet pan should be well flushed. If other conveniences be near, 
the rest of the household should use them during, and some time after, 
the illness, 

1087. After convalescence the sick-room must be thoroughly cleansed. 
Clothes which cannot be washed must be burned. The bed, mattress, 
and carpets must be baked in a hot oven ; oil paint scoured, the ceiling 
whitewashed, the walls re-papered, the floor scalded, and afterwards 
scrubbed. The door should be kept shut, and the windows open, and a 
large fire should be kept up during, and for some days after, the cleans- 
ing. Boiling water, is a thorough disinfectant. We may use such dis- 
iniectants as charcoal, chloride of lime, chloride of zinc (Burnett's 
fluid), permanganate of potash (Condy's fluid), and carbolic acid, in 
addition, but we must not trust to these alone. 



( 255 ) 

PART II. 

PRACTICE OF MEDICINE. 



CONTENTS. 

GENERAL DISEASES. 



Chapter 1. States of the system. 

2. Local diseases, affecting all or several of the organs or 

textures of the body. 

3. Febrile diseases without essential local complication. 

4. Febrile diseases with essential local complication. 

5. Febrile diseases arising from local causes. 

6. General diseases (not febrile), with essential local compli- 

cation. 

SPECIAL DISEASES. 

Chapter 1. Diseases of the nervous system. 

2. Diseases of the organs of circulation. 

3. Diseases of the organs of respiration. 

4. Diseases of the organs of digestion, and abdominal viscera. 

5. Diseases of the urinary organs. 

6. Diseases of the organs of generation. 

7. Diseases of the organs of sense. 

8. Diseases of the skin and its appendages. 

9. Parasitic animals. 

10. Poisons and their antidotes. 



1. Classification of remedies, and formula?. 

2. Glossarial index. 



( 256 ) 



GENEEAL DISEASES. 



CHAPTER I. 

STATES OF THE SYSTEM. 

Plethora. ...... The Plethoric State. 

ANjEMIA The Anemic State. 

Cachexia The Cachectic State. 

MiMOSiS Jnquieta .... The Nervous State. 

Febricela The Febrile State. 

The subjects treated in this chapter have peculiarities which entitle them 
to a place by themselves. They are rather disordered states of system 
than diseases properly so called. They consist in a departure from health, 
more or less permanent, not necessarily complicated with any local affec- 
tion, and often present and cognisable in combination with specific and 
well-defined maladies. A plethoric, an anaemic, or a cachectic patient, or 
one suffering from extreme debility, or from a group of nervous symp- 
toms, may become the subject of one and the same disease, such as typhus 
fever or small-pox, which disease will be materially influenced in its 
character, progress, and termination by that pre-exist ent state of system. 
The treatment also which it may be proper to adopt, with a view to the 
cure or relief of the patient, will be materially influenced, and in some 
cases altogether determined, by the state of system on which the disease 
has supervened. Again, in all those diseases in which the symptoms are 
obscure, or the appropriate remedy not yet discovered, the only course 
open to the physician is to direct his prescriptions to the state of system. 
IS'or ought it to be forgotten that these states of system may be them- 
selves brought on by several analogous local or general causes, and that 
to recognise the state of system is to possess a clue to the often obscure, 
and little suspected, origin of the existing disorder. For these reasons 
the contents of this chapter are placed by themselves, and take prece- 
dence of diseases properly so called. 



PLETHORA.— THE PLETHORIC STATE. 

Synonyms. — General Hyperasmia. — Polysomia. — Fulness of blood. 
— A full habit of body. 

Definition. — A state of system characterised by an excessive quan- 
tity of blood, or by an excess of its more solid constituents. 



THE PLETHOKIC STATE. ZO i 

.Symptoms. — The general aspect of the body full and florid ; the capil- 
laries of the surface injected ; the redness of the skin momentarily re- 
moved by pressure ; the lips red ; the eyes bright, and the conjunctiva 
injected ; the tongue clean and red, or slightly furred ; the appetite 
generally good ; the bowels usually confined ; the skin dry, but per- 
spiring profusely on exertion; the pulse frequent, full, firm, and bound- 
ing. In the more strongly-marked cases, the pulse is infrequent, indis- 
tinct, and labouiing, or irregular in force and frequency, according to 
the degree in which the heart is oppressed ; the extremities are cold ; 
the patient is weak, listless, and easily fatigued, and suffers from palpi- 
tation and shortness of breath, and frequent sighing on exertion ; and 
complains of giddiness, noises in the ears, bright or dark spots before the 
v-yes, and a dull heavy pain in the head. 

Terminations. — In local congestions, inflammations, and haemor- 
rhages ; in apoplexy, especially in peisons with large chests and short 
necks ; in hypertrophy of the heart ; in gout. 

Pathology. — This disorder consists in an excessive quantity of blood, 
or, the quantity remaining unchanged, in a superabundance of red par- 
ticles and nbrine. 

Causes. — Predisposing : A peculiar habit of body, with, large chest 
and short neck. Exciting: A highly nutritious diet; beer and spiri- 
tuous liquors ; sedentary habits ; too much sleep ; inadequate exercise, 
with free exposure to the air ; suppression of the catamenia. 

Diagnosis. — This state is easily recognised by the fulness of the whole 
capillary system, and the rapid filling of the vessels of the surface on the 
removal of pressure. 

Treatment. — Indication : I. To lessen the quantity of blood. II. 
To increase the actions of the emunctory organs. 

In the common run of cases, this indication is best fulfilled by a spare 
diet, abstinence fiom malt and spirituous liquors, early rising, regular 
exercise, and the frequent use of saline aperients. Forms. 260, 262. 

In extreme cases, and where there is a threatening of local disease, 
bleeding fiom the arm should be practised in addition to the treatment 
just prescribed. As a general rule, small bleedings are to be preferred ; 
but in some cases the system will bear the removal of forty ounces, or 
more. The blood should be taken from a small orifice, in the semi-erect 
jr recumbent posture, and the pulse should be examined to ascertain 
the effect produced. When it is frequent, full, and bounding, blood 
may be drawn till it falls to its natural frequency and force ; if labour- 
ing, till it becomes full and free; if irregular, till it becomes regular. 
But, as a general rule, it is better to avoid the letting of blood, and to 
trust to the prolonged use of abstinence, exercise, early rising, and saline 
aperients. If amenorrhcea be present, four or six leeches may be applied 
to the groin at the menstrual periods. If apoplexy or gout impend, the 
treatment must be modified accordingly. 

Prophylaxis. — To prevent the rapid formation of blood, the diet 



258 THE AJ3MMIC STATE. 

should be plain and somewhat restricted, with total abstinence from 
malt or spirituous liquors ; perspiration must be promoted by brisk ex- 
ercise, and the bowels kept free by suitable aperients* 



ANEMIA— THE ANEMIC STATE. 

Definition. — A state of system characterised by a diminution in the 
quantity of the blood, or of the red particles and other solid ingredients. 

Varieties. — 1. Anaemia from loss of blood. 2. Chronic anaemia. 
3. Cachectic anaemia, or chlorosis. 

1. Anaemia from Loss of Blood. 

Symptoms. — The most familiar of the effects of loss of blood for of 
profuse discharges rapidly poured out | is syncope, of which the symp- 
toms are giddiness, followed by loss of consciousness ; suspension of re- 
spiration alternating with deep sighs : the pulse and beat of the heart 
scarcely, if at all, perceptible ; the surface pale, and bedewed with cold 
perspiration. Recovery takes place with momentary delirium, yawning, 
deep sighs, sickness, and a gradual return of colour to the skin, and of 
] the heart and wrist. This fainting state is followed by reaction, 
and recurs from time to time on slight exertion, or change of postuie ; 
but in fatal cases the symptoms become gradually and progressively 
worse ; the countenance paler and more sunken ; the extremities colder 
and colder; the breathing hurried and interrupted by deep sighs or 
yawns, panting, gasping, or stertorous ; the pulse imperceptible ; rest- 
lessness and jactitation are followed by coma, or convulsions ; at length, 
the patient's strength is exhausted, and he sinks, gasps, and expires. 
Death is occasionally the consequence of suddenly assuming the sitting 
or standing posture. 

The state of reaction is characterised by peculiar and strongly-marked 
symptoms : by forcibly beating of the carotids, with a sense of throbbing 
and tension in the head : palpitation of the heart, throbbing at the pit 
of the stomach, and in the course of the aorta, and a frequent, bounding, 
and often irregular sharp pulse ; a hurried, panting, sighing, respira- 
tion; restlessness, jactitation, and mental agitation; intolerance of light 
and sound ; the sleep disturbed by fearful dreams ; the waking hurried 
and perplexed. Violent delirium, mania, coma, amaurosis, and deafness 
are among the concomitants of this state. 

Post-mortem Appearances. — An empty state of the cavities of 
the heart ; and general pallor of the viscera, most marked in the lungs. 

Diagnosis. — The extreme pallor of the face, skin, lips, and gums in- 
dicate the diminution of the blood. 

Treatment. — Indications. I. To stimulate the brain with the 
blood that still remains. 11. To maintain the action of the heart bv ex- 



CHBONIC ANEMIA. 259 

iernal and internal stimulants. III. To subdue abnormal nervous action. 
IV. To promote the formation of new blood. 

The first indication is fulfilled by placing the head on a level with the 
chest ; the second, by the free exhibition of ammonia, wine, or brandy, 
and the application of cloths wrung out of hot water, or of sinapisms to 
the region of the heart ; the third, by a full dose of opium, such as 5i. 
of the tincture, which, in an urgent case, is obviously preferable to the 
solid preparations of the drug. If violent delirium or acute mania be 
present, as a consequence of the loss of blood, we may repeat the sopo- 
rific at intervals of three or four hours, according to the effect produced. 
Convulsions declare the most imminent danger, and if the means are at 
hand we should use transfusion of blood from the arm of another person. 
Galvanism and artificial respiration may be resorted to as a last means 
of restoration. The formation of new blood will be promoted by the in- 
troduction of thin gruel, beef- tea, or an emulsion of egg and milk into 
the stomach, or, if the power of deglutition fail, into the rectum. Having 
once re-established the circulation, the subsequent treatment will be that 
suited to chronic anaemia. For a time the erect or sitting posture must 
be strictly interdicted. 



2. Chkonic Anemia. 



Definition. — A state of system coming on gradually, continuing 
generally for some weeks or months, and dependent on a deciease in the 
red particles and solid constituents of the blood. 

Symptoms. — Universal pallor of the skin, conjunctiva, gums, and 
membrane of the mouth ; dead whiteness of the tongue ; cold extremi- 
ties ; debility ; fainting fits ; palpitation and dyspnoea on the slightest 
exertion, with violent pulsation of the carotid arteries ; headache, con- 
sisting generally in a fixed pain over the eyebrows or on the top of the 
head ; pain under the left breast, or a sense of fulness in the chest ; pulse 
frequent, small, and quick (in extreme cases aptly described as jerking), 
increased by exertion and emotion. The patient is easily agitated by 
slight noises or unexpected events, and suffers from depression of spirits, 
and, in some cases, from hysteric fits ; the secretions and excretions are 
generally scanty, and the bowels often torpid. 

Physical Signs. — On applying the stethoscope over the large veins 
of the neck in the supra-clavicular space, especially on the right side, 
a humming sound (bruit de diable — humming-top sound, or venous 
murmur) is heard, flight pressure of the stethoscope upon the larger 
arteries produces a bruit de soujflet, sometimes resembling the soft 
sound caused by blowing across the mouth of a bottle ; at others it is 
shorter and harsher, like the puffing of a locomotive engine. A soft 
blowing sound is frequently heard at the base of the heart. In the space 
above the clavicle the venous murmur and the arterial bellows sound are 
often heard at the same time. These are doubtless indications of a flac- 
cid condition of the aiterial and venous tubes. They are not peculiar 



260 CACHECTIC ANEMIA. 

to anaemia, nor are they required as diagnostic marks when the pallor of 
the surface is well marked. 

Complications. — It is often, but not always, associated in the female 
with amenorrhoea, or with scanty menstruation. 

Causes. — Predisposing. The female sex, and the age of puberty, or 
the period preceding or following it. It is rare in males. Exciting. In 
females obscuie. but connected with the function of menstruation. In 
males occasioned by overwork ; as with compositors, bakers, and others, 
who work much of their time in dark, hot, and ill- ventilated rooms. 
For other exciting causes of the allied state Cachexia, see Cachexia. 

Prognosis. — Favourable ; but recovery sometimes slow and tedious. 

Diagnosis. — From chlorosis, by the absence of disorder in the func- 
tions of the alimentary canal. The soft basal bellows murmur must not 
be attributed to organic heart disease. 

Treatment. — Indication. 1. To promote the formation of the red 
particles and solid constituents of the blood. This indication is fulfilled 
by the use of the preparations of iron in full doses, together with a nou- 
rishing diet. The best preparation of iron is the dried sulphate, of which 
five grams may be taken three times a day. If the bowels be torpid, 
the pilula aloes et myrrhae may be given every night, or as often as may 
be required. 

I have given the dried sulphate of iron, combined with extract of gen- 
tian, in ten-grain doses ; and an anaemic female, who takes these pills as 
others take stimulants, swallowed on one occasion twelve pills, contain- 
ing half a drachm of sulphaxe of iron, in one day. The same prepara- 
tion, in the same liberal doses, may be given with like advantage in the 
few cases of anaemia that occur in the male subject. (G.) 

A generous diet, with a moderate allowance of wine, is indicated in 
cases of anaemia accompanied by marked debility ; and exercise in the 
fresh air, proportioned to the strength of the patient, should be insisted 
on. When the spirits of the patient are depressed, change of air and 
scene, and the use of chalybeate waters, may be recommended. The 
shower-bath, and sea-air with sea-bathing, may also be prescribed with 
advantage. 

Mercurial preparations should be given with caution, as there is reason 
to believe that salivation is very readily brought on in anaemic patients. 



3. Cachectic Anaemia, or Chlorosis (Creen Sickness). 

Definition. — A state of system partaking of the characters of anae- 
mia and cachexia ; and combining an altered state of the blood with a 
depraved state of the secretions. 

Symptoms. — A greenish-yellow pallor of the skin, puffiness, and often 
oedema of the integument : heaviness ; listlessness ; fatigue on the least 



CACHEXIA. 261 

exertion : palpitations ; throbbing of the carotid arteries ; shortness of 
breath ; pains in the back, loins, and hips ; indigestion, with flatulency 
and acidity in the stomach ; offensive breath, and disordered bowels, with 
offensive evacuations. The appetite is often singularly depraved ; lime, 
chalk, and other absorbents are sometimes greedily eaten, and the accus- 
tomed food rejected. 

As the disease advances, the lips lose their colour ; the eyes are en- 
circled with a livid areola, the face becomes pale, and assumes a dusky 
yellowish hue ; the feet are affected with cedematous swellings ; there is 
every indication of want of power and energy. The breathing is hurried 
by the slightest exertion ; and the pulse is small, quick, and frequent. 

Causes. — Those of anaemia and cachexia combined. Amenorrhea is 
a general, though not a constant, accompaniment. 

Treatment. — Indications. I. To restore the normal character of 
the blood by the means recommended in the treatment of chronic anae- 
mia. II. To correct the depraved secretions. 

The second indication may be fulfilled by gentle aloetic aperients, com- 
bined with myrrh and a little blue pill. 

The menstrual function, in most cases, need not be interfered with, 
but if any urgent uterine symptoms be present, they must be treated by 
the remedies pointed out under amenorrhcea, dysmenorrhea, &c. 



Cachexia— Cachexy, Bad Habit of Body. 

Definition. — An unhealthy state of system, allied to ansemia, and 
due to some poison gradually introduced into the body, or generated 
within it, circulating in the blood, and giving rise to important changes 
in its composition. 

Varieties. — Syphilitic Cachexia. Alcoholic Cachexia. Marsh Ca- 
chexia. Tubercular Cachexia (Tuberculosis). Carcinomatous Cachexia. 
Cachexia of hot climates. Leucocythsemia. Supra-renal cachexia. 

Symptoms. — A sallow, dusky, or muddy complexion, often tinged 
with yellow ; a dry and harsh skin ; a small, frequent, and compres- 
sible pulse ; the tongue sometimes clean, moist, and red, sometimes pale, 
but more commonly furred, or cracked ; the appetite capricious, often 
craving and voracious ; dyspeptic symptoms ; the bowels either costive 
or loose, with dark, slimy, and offensive faecal discharges; the urine 
generally high coloured, of a strong odour, and depositing amorphous 
lithates ; the perspiration and breath offensive. Enlarged tonsils, apntha?, 
and cutaneous eruptions, are frequent concomitants of this state, as are 
also obscure and wandering pains of the body and limbs. 

Terminations. — In organic diseases of the internal viscera, espe- 
cially the lungs, liver, and kidneys ; these diseases being often compli- 
cated with ascites or anasarca. 



262 CACHEXIA — LEUKEMIA. 

Causes. — Predisposing. Debility in infancy, and hereditary defect 
of constitution. Exciting. Unwholesome diet ; want of proper exercise ; 
intemperance ; continued exposure to marsh miasma, to a cold, damp 
atmosphere, or to unhealthy climates ; the impure air of crowded cities : 
the gradual operation of mineral poisons, such as mercury, lead, copper, 
and arsenic; and of animal poisons, especially the syphilitic virus. 

Prognosis. — Favourable, if the patient can he removed from the in- 
fluence of the ascertained cause, and in the absence of organic disease. 
Unfavorable, when complicated with severe visceral disease. 

Treatment. — Indications. I. To remove the exciting cause. 
II. To improve the condition of the circulating fluid. The exciting 
cause may be removed, in the several cases specified, by proper diet, exer- 
cise, change of air, ventilation of apartments in which unhealthy occupa- 
tions are carried on, change from unwholesome employments to healthy 
occupations. In the case of syphilitic cachexy a new action must be in- 
duced in the system by preparations of mercury or of iodine. The con- 
dition of the circulating fluid may be improved by a diet consisting of a 
due mixture of animal and vegetable food. The condition of the digestive, 
cutaneous, urinary, and uterine functions must be carefully inquired 
into, and the nature of the secretions determined. If the bile be vitiated 
and defective, alkalies combined with tonics, and mercurial purgatives, 
should be given. The condition of the urine will generally indicate the 
treatment which should be adopted. If it be loaded with phosphates or 
oxalates, the mineral acids may be given in combination with quinine. 
If lithates be present, alkalis, with tonic and .stimulant infusions, are 
required. The skin must be roused into healthy action by means of 
daily shower or sponge baths, followed by friction of the surface with a 
brush or coarse towel. If the temperature be low, an occasional hot bath 
should be taken at bedtime. Change of air and of scene, and chalybeates 
or saline waters, may be resorted to with the greatest benefit. 

Of the varieties of cachexia specified above, some will be found suffi- 
ciently described under the diseases which produce them; others, as 
leucocythasmia and supra-renal cachexia, require separate notice. 

Leucocytieemta, Leukemia, Lympilemia, is a form of cachectic 
anaemia, for a knowledge of which we are indebted to Dr. Bennett of 
Edinburgh. The disease derives its name from an excess of white cor- 
puscles in the blood. It is characterised by great pallor of surface, ac- 
companied in some cases by oedema, or by dropsical effusions of greater 
or less extent. The functions of the stomach and bowels are generally 
deranged, and jaundice is sometimes present. There is great weakness 
and emaciation, shortness of breath, and, in cases of long standing, hectic 
fever. The blood is found to contain white corpuscles in great excess. 
The disease is generally one of adult life, and is commonly associated with 
disease of the liver and spleen, especially the latter, which is often greatly 
enlarged. Disease of the lymphatic glands is also a common accompani- 
ment. The disease is essentially chronic, and the prognosis unfavourable, 
except in those rare cases in which the viscera are not seriously affected. 



CACHEXIA — MELASMA. 263 

The cause of the disease is sometimes to be found in severe attacks of re- 
mittent or intermittent fevers, leaving behind them disease of the liver 
and spleen. The treatment will consist in the simultaneous use of pre- 
parations of iron, and of the remedies indicated for the concomitant visceral 
disease. 

Virchow distinguishes two forms of leukaemia, the splenic and the 
lymphatic, the spleen being the starting-point of the disease in the one, 
and some portion of the lymphatic glands in the other : in the splenic 
form the white corpuscles of the blood are comparatively large, well-de- 
veloped cells, with one or more nuclei closely resembling the cells of the 
spleen. In the lymphatic form the white blood corpuscles are small, and 
each has a single, somewhat granular nucleus, closely attached to the 
cell- wall. " In many instances it looks as if perfectly free nuclei were 
contained in the blood." 

Cachexia of Hot Climates. — This is of common occurrence in 
Europeans resident in hot climates : sometimes as the consequence of 
organic disease of the abdominal viscera brought on by previous attacks 
of intermittent or remittent fever ; sometimes as the result of a prolonged 
residence in unhealthy localities without any precedent organic malady ; 
sometimes, again, as the sequel of febrile attacks, not followed by organic 
mischief. It may also be induced by the injudicious use of the lancet, 
or by attacks of diarrhoea, cholera, dysentery, scurvy, or hepatitis. The 
leading symptoms are, a pale and sallow countenance, a cold and shrivelled 
skin, a pearly whiteness of the eye, a dilated pupil, a dull and languid 
expression of features, a peevish temper, and a despondent state of mind. 
The belly is generally swollen, and the extremities often cedematous, the 
digestion weak, the bowels torpid, the tongue pale, and coated with a 
white fur, the pulse feeble, and the respiration easily quickened by exer- 
tion. The treatment proper for this state consists in the use of the pre- 
parations of iron, with aloetic aperients, if required, and such local treat- 
ment as the visceral complications require, with strict attention to all the 
means of preserving health. A dry and bracing air, mental rest, and 
suitable bodily exercise, must be particularly insisted on. Preparations 
of mercury are contra-indicated. 

I have, in one or two instances, seen this state of system following- 
service in hot climates and attacks of intermittent or remittent fever, 
without, however, any serious disease of the liver or spleen, speedily and 
entii ely cured by the use of preparations of steel. (G.) 

Supra-renal Cachexia. — Supra-renal Melasma, Morbus Addi- 
sonii. — This is a form of cachexia characterised, like leucocythsemia, by 
great pallor of surface, pearly whiteness of the conjunctiva, great languor 
and debility, loss of appetite, an uneasy feeling at the pit of the stomach, 
and sometimes vomiting of food, feeble pulse, and some loss of flesh. This 
anaemic and cachectic state is accompanied by a peculiar and characteristic 
discoloration of the skin over the whole surface of the body, but more 
particularly on the face and neck and under the eyes, on the penis and 
scrotum, the armpit and navel, the epigastrium and upper extremities. 
The skin has a smoky appearance, and presents every shade of colour 



264 MIMOSA INQUIETA. 

from amber to dark chestnut, or even a chocolate colour. It is some- 
times blended with spots or patches of morbid whiteness. The discolora- 
tion may also atiect the inside of the cheeks and the lips, which some- 
times have the appearance caused by eating mulberries. The cases in 
which this discoloration is extensive and strongly marked ; end fatally. 

Cause. — Doubt still remains in the minds of many as to the connec- 
tion between these symptoms and disease of the supra-renal capsules. We 
are indebted to Dr. Headlam Greenhow for having collected and analysed 
all the published cases of so-called Addison's disease. The following are 
the results at which he has arrived : — There were ten cases of bronzed 
skin in wh'ch the supra-renal capsules were healthy ; twenty-four in 
which they were in part or wholly destroyed by cancerous deposit but 
in eight only of which was there any cutaneous discoloration approach- 
ing to bronzing ; thirty-four cases of miscellaneous affections of the cap- 
sules, in only sixteen of which was there any decided bronzing ; fifty-nine 
cases in which the degeneration of the capsules was associated with tuber- 
cular and vertebral disease; twenty- three in which the capsular disease 
was associated with phthisis and other serious diseases ; five in which 
the state of the other organs was not reported ; thirteen in which the 
supra-renal disease was complicated with disease of the mesenteric and 
intestinal glands, or of the lungs or pleura ; and only tw T enty-eight cases 
in which the disease of the capsules was absolutely unaccompanied by 
constitutional disease. In even some of these latter, death may have been 
due to general fatty degeneration and asthaenia, for some of the subjects 
were overladen with fat. Dr. Greenhow rejects the fiist sixty-four cases 
in this enumeration as spurious examples of Addison's disease. 



MIMOSIS INQUIETA— THE NERVOUS STATE. 

Symptoms. — Flushings, tremblings, palpitations, dyspnoea, pain in the 
left side, giddiness, loss of recollection, depression of spirits, anxiety, and 
timidity. In extreme cases the patient is startled by the slightest noise ; 
is in constant apprehension of death, or of some great evil about to befall 
him ; he imagines that he has done something wrong ; or is in constant 
fear that he may commit some great crime. The sleep is often disturbed 
by frightful dreams. Neuralgic pains, with extreme weakness of the 
hands and forearms, are of common occurrence, and gives rise to an un- 
founded alarm of paralysis. There are indigestion and flatulence, and 
the bowels are frequently costive. In other respects the health does not 
suffer materially. The patient often looks well, does not lose flesh, and 
may even be of a full habit of body. In women, fain tings and hysterical 
paroxysms are sometimes superadded, and the disease occasionally termi- 
nates in mania. 

Causes. — Predisposing . A nervous temperament. Excessive dis- 
charges, such as hyperlactation, leucorrhoea, menorrhagia, diarrhoea, and 
repeated loss of blood, the change of life, in the female sex. Exciting. 






THE FEBRILE STATE. 265 

In both sexes, fright, grief, anxiety, overwork, scanty nourishment, or 
fatigue. In men, excessive study, anxiety, dissipation, and sexual abuse. 

Diagnosis. — From serious nervous diseases, snch as delirium tremens, 
and mania, by the absence of delirium, and of obstinate delusions. 

Prognosis. — Favourable, but recovery generally slow and tedious. 

Treatment. — I. Support the patient's strength by the use of as- 
tringent tonics (Form, lb 7), a generous diet, a moderate amount of 
wine, fresh air, and exercise. II. Allay the nervous irritation by the 
use of sedatives, such as opium, hyoscyamus, and digitalis. 



FEBRICULA— THE FEBRILE STATE. 
Synonyms. — Febris ephemera. Simple fever. Fevenshness. 

Definition. — A continued fever, of slight degree and short duration, 
which often runs its course in twenty-four hours. 

Symptoms. — Increased heat of skin and frequency of pulse, flushed 
face, slightly furred tongue, thirst, loss of appetite, restlessness, lassitude, 
and wandering pains in the head, back, and limbs, are the ordinary 
symptoms of the febrile state. They are sometimes ushered in by 
shivering, and generally pass otf by perspiration. 

Causes. — Fatigue ; exposure to cold ; heated rooms ; intemperance in 
eating or drinking ; slight local inflammation. The contagion of typhus 
fever acting on a strong constitution, or that of any of the exanthemata 
acting on a person who has already had the disease. 

Diagnosis. — From severe forms of continued fever by the mildness 
of the symptoms. Caution, however, is necessary in expressing an 
opinion, as at the first onset of severe cases of continued fever and of the 
febrile exanthemata, the symptoms are often not strongly marked. 

Prognosis. — Favourable, but guarded, for the reason just stated. 

Treatment. — I. If the febrile attack have originated in intemper- 
ance in eating or drinking, an emet'c should be administerel. 

II. The feverish symptoms w T ill generally yield to a saline aperient 
(Form. 259), and low diet. In more severe cases, ten grains of Dover's 
powder may be given at bed-time, followed by a saline aperient in the 
morning. The patient should keep his bed for a day, and be restricted 
to tea, farinaceous food, and cooling drinks. 



( 266 ) 



CHAPTER II. 

Phlogosts Inflammation. 

Congestio Congestion. 

Hemorrhaged Haemorrhage. 

Hydrops Dropsy. 

Erysipelas St. Anthony's Fire. 

PHLOGOSIS— INFLAMMATION. 
Varieties. — 1. Acute. 2. Chronic. 

1. Acute Inflammation. 
Symptoms. — These are — (1.) Local. (2.) General or Constitutional. 

(1.) Local Symptoms. When External. — Redness, swelling, heat, 
and pain. The redness arises from the increased quantity or* red blood 
contained in all the vessels of the part ; the swelling from the same cause, 
combined with the exsudation of serum, albumen, or lymph ; the heat 
exceeds that of other superficial parts, but never rises higher than that 
of the blood ; the pain is explained by the larger supply of blood to the 
nerves of the part, combined with the pressure of the surrounding tex- 
ture upon them. It is accordingly most severe when the surrounding 
textures are most unyielding, as in whitlow; comparatively slight, or only 
produced by external pressure, in the lax mucous membranes. When 
internal. — There is pain and disturbance of function. The pain, in parts 
which can be submitted to pressure, is increased by that pressure, and 
this forms an important means of diagnosis ; and, in the less severe forms 
of inflammation, pain not existing before is sometimes brought out by 
pressure. The disturbance of function in secreting organs, consists in 
alteration, diminution, or total suppression of their appropriate secre- 
tions, according to the degree of the inflammation : in other organs, it 
consists of various degrees of excitement — in the brain, rapid succession 
of ideas, mental irritation, delirium ; in the eye and ear, intolerance of 
light and sound, or false sensations, such as flashes of light, musical 
notes, &c. ; in the lungs, dyspnoea ; in the heart, palpitation. 

(2.) General or Constitutional Symptoms. — In healthy persons, the 
group of symptoms commonly known as Inflammatory Fever ; namely, 
rigors, succeeded by pains in the head, back, and limbs ; lassitude ; 
nausea, and loss of appetite ; increased heat of surface ; thirst ; furred 
tongue ; frequent, full, hard pulse ; dry skin ; scanty, and high-co- 
loured urine ; and constipation. There is a slight aggravation of the 
symptoms towards evening, and a slight remission in the morning. The 
sleep is disturbed, and the patient is somewhat delirious. After blood is 
drawn it is found cupped and buffed. 



! 



INFLAMMATION. 267 

In severe and extensive inflammation, or in unhealthy persons, the 
symptoms are those of Constitutional Irritation : characterised by ex- 
treme anxiety and restlessness ; hurried respiration ; rigors ; a frequent, 
quick, sharp pulse ; low muttering delirium ; and in fatal cases, death 
by exhaustion. 

In extremely debilitated subjects, hectic fever is commonly present 
as soon as pus is formed. 

Terminations. — 1. Resolution. 2. Increased secretion. 3. Haemor- 
rhage. 4. Adhesion. 5. Softening. 6. Induration. 7. Suppuration. 
8. Gangrene. 

Causes. — Predisposing. Sanguine temperament ; full habit of body ; 
general debility; cachectic and febrile states of system. Exciting, — 1. 
Mechanical and chemical irritants. 2. Cold and heat, 3. An altered 
or poisoned condition of the blood. 4. Local congestion, from imperfect 
elimination of effete matters. 

Causes which Modify the Character of Inflammation : — 

1. Texture. 2. Condition of System. 1. Texture. — The serous 
membranes when acutely inflamed take on the adhesive inflammation, 
very rarely the suppurative ; in less degrees of inflammation, they pour 
out serum or liquid albumen. The mucous membranes secrete mucus, 
pus, and, in rare cases, coagulable lymph, and are prone to suppuration 
and to softening, but not to adhesion of oppose! surfaces. Inflammation 
of the cellular tissue causes a secretion of serum, and, in higher degrees 
of inflammation, of coagulable lymph and pus. Its common termination 
is by abscess. Inflammation of the cellular tissues is called phlegmonous 
inflammation. The parenchymatous substance of organs is apt to be 
softened by acute, and hardened by chronic inflammation ; it is also liable 
to abscess and gangrene. Of the fibrous tissues, tendon and ligament 
are prone to gangiene, cartilage to ulceration. Osseous inflammation 
terminates in gangrene (caries and necrosis). The skin resembles the 
mucous membranes in being prone to suppuration. Diffused redness, 
pimples, and gangrene are also common terminations of cutaneous in- 
flammation. Vesicles, pustules, and spots of ulceration and gangrene 
also occur on the skin, and constitute a great variety of skin diseases. 

The general, or constitutional symptoms of inflammation also vary 
materially with the tissue affected. In inflammation of the serous mem- 
branes, the;e is little heat of surface, little muscular debility, little ten- 
dency to delirium, unless the serous membranes of the brain be affected ; 
the pulse is hard ; there is acute pain, great tolerance of loss of blood, an 
excess of fibrine, and a cupped and buffed appearance in the blood itself. 
In inflammation of the mucous membranes, on the other hand, there is 
little pain, little tolerance of loss of blood, no increase of fibrine, and the 
absence of the cupped and buffed appearance. 

2. The plethoric are liable to boils, carbuncles, and adhesive inflam- 
mation of the serous membranes. In the anaemic there is but little ten- 
dency to inflammation, and when it occurs, it is subacute, and generally 



268 PHLOGOSIS. 

results in serous effusions and acute oedema. In the cachectic state 
there is liability to those low forms ot inflammation which result in the 
deposition of croupy or diphtheritic exsudation upon the mucous mem- 
branes ; in the formation of tubercle in the lungs and lymphatic glands ; 
or the outpouring of sero -purulent fluid into the serous cavities. 

It is of the utmost importance that the practitioner should be familiar 
with the constitutional symptoms which mark the several terminations 
of inflammation. Acute ad tesive inflammation is accompanied by a full, 
strong, and hard, or a small wiry pulse, somewhat increased in frequency, 
little or no heat of skin, little or no headache, vertigo, or delirium, no 
muscular tremor or debility, slight change in the character of the urine, 
and great tolerance of bloodletting. Suppuration is announced by burn- 
ing, throbbing pain, by severe and often by repeated rigor, occurring in 
some cases almost with the regularity of ague, and followed by heat and 
sweating — the symptoms, in tact, of hectic fever. Gangrene is indicated 
by a sudden cessation of pain, by collap-e of the entire system, pallor, 
cold clammy sweat, sunken features, sometimes low delirium, sometimes 
peculiar self-possession. A dry, brown tongue, sordes on the teeth, a 
small, frequent, feeble pulse, and the other symptoms ot the typhous state, 
usually precede the fatal termination of extensive or long-continued in- 
flammations. 

Treatment. — The remedies employed in the treatment of acute in- 
flammation are either general or local. The general remedies are blood- 
letting by venisection or arteriotomy, the tartarate 1 antimony, in full 
doses of a fourth of a grain or more, and the preparations of mercury, espe- 
cially calomel and blue pill, administered in i epeated doses, so as to pro- 
duce slight constitutional effects. In slight inflammations the use of strong 
saline aperients will be sufficient. In internal inflammations, diaphore- 
tics, aided by the hot bath, are of the greatest service. The local remedies 
are depletion by leeches, cupping, or scarification, incisions into the part, 
cold, cataplasms and fomentations, and counter-in itants. Inflammation 
of exposed mucous surfaces is often treated by strong irritants, such as 
nitrate of silver, which have the effect of promoting the contraction of the 
dilated vessels. Another effective local remedy is pressure, which has 
been applied with advantage in orchitis and in anthrax. 

2. Chronic Inflammation. 

Symptoms. — Those of the acute form, but less intense, and of longer 
duration. The redness is of a more dusky hue ; the heat little, if at all, 
above the natural standard, and the pain very slight, or only produced 
by pressure. The functions of internal parts when thus inflamed are 
generally languid, and their secretions are diminished in quantity. In 
chronic inflammation of the cellular tissue, serous effusions usually take 
the place of the more solid products of acute inflammation. 

Treat.mfnt. — This is chiefly by local remedies, of which those most 
in use are, moderate depletion by leeches or cupping, stimulants, which 
cause the capillaries to contract, and counter-irritants. Of stimulants, 



CONGESTION. 269 

the most efficacious are nitrate of silver, tincture of iodine, iodine oint- 
ment, &c, applied over and around the inflamed part. The capillaries 
may also be caused to contract, and chronic effusions may be removed, 
by the cold douche, or by electric shocks passed through the part affected. 
In chronic inflammation of the lower extremities, a graduated pressure 
is also of great service, by supporting the relaxed vessels. Iodine and 
its preparations are of use internally to promote the absorption of effused 
mateiial. 



CONGESTIO— CONGESTION. 

Varieties. — 1. Active. 2. Passive. 

1. Active Congestion. — Sthenic or active Hyperemia. 

Characters. — A local fulness of the small vessels, analogous to that 
general fulness which constitutes plethora ; this fulness being accompanied 
by a more rapid flow of blood, attended by the same florid redness which 
is present in inflammation. 

Terminations. — In inflammation. In active haemorrhage. In pas- 
sive congestion. In dropsy. 

Treatment. — When congestion threatens to run on into inflamma- 
tion, the moderate abstraction of blood from the part by leeches or cup- 
ping, a position favourable to the return of blood to the heart, the local 
application of cold, counter-irritants, and the administration of saline 
aperients and tonic stimulants, are indicated. 

2. Passive Congestion. — Passive or Asthenic Hyperemia. 

Characters. — Distension of the capillaries and small veins, a lan- 
guid circulation of blood through the part, and a dusky hue. 

Terminations. — In active congestion, passing on into inflammation. 
In oppressed and sluggish function. In dropsy. In passive haemor- 
rhages, leading to chronic ulcers of the extremities. 

Causes. — Mechanical pressure. Obstruction to the flow of blood 
through the lungs, the heart, or the liver. A position unfavourable to 
the free return of blood to the heart. Constitutional debility. Cold. 
Imperfect action of secieting and excreting organs. 

Treatment. — Must be suited to the cause. Leeching ; dry cup- 
ping; friction. In congestion of the mucous membranes, and in con- 
gestion or chionic ulceration of the integuments, the use of stimulant 
and astringent applications. The moderate use ot aperient medicines, 
to relieve the general circulation ; of stimulants to excite it ; and of 
tonics to support it. 



270 H^MORRHAGIA — HYDROPS. 



aaEMORRHAGIA— HEMORRHAGE. 

When haemorrhage arises in healthy states of system from strong 
action of the heart, it is called active ; when from a weakened stale of 
capillaries, passive : that which arises from congestion might be termed 
with equal propriety congestive haemorrhage. 

1. Active Haemorrhage. 

Characters. — A sudden discharge of bright-coloured blood. 

Causes. — Predisposing. Youth and vigour. Plethora. Exciting. 
All excitements of the circulation by violent muscular exertion; the 
abuse of spirituous liquors; violent passions and emotions. The imme- 
diate cause may be the rupture of a large artery, or of an aneurismal 
sac ; active congestion of a mucous surface leading to extravasation ; 
the laying bare of an artery by ulceration ; and severe wounds. 

Treatment. — That appropriate to acute inflammation, nauseating 
doses of tartar emetic (Form. 210), brisk saline aperients, and low diet. 
A position unfavourable to the flow of blood towards the seat of the 
haemorrhage. Quiet and rest of the part affected. Cool air and cooling 
drinks. Cold applications. Ice. Styptics. In debilitated constitu- 
tions, iti addition to a proper posture, rest, cool air, and cooling drinks, 
astringent medicines should be prescribed, such as the mineral acids, 
especially the sulphuric, the preparations of zinc and lead, and vegetable 
substances containing tannin or gallic, acid. In all cases of extreme 
debility, with great pallor of surface, brought on by excessive haemor- 
rhage, opium and its preparations in full doses are indicated, either by 
themselves or in combination with astringents (Form. 83). 

2. Passive Hemorrhage. 

Characters. — A slow discharge of dark-coloured blood by extrava- 
sation from mucous or other surfaces in a state of passive congestion. 

Treatment. — That of passive congestion, supia. 



HYDROPS— DROPSY or ANASARCA. 

Definition. — An effusion of serum into the interstices of the areolar 
tissue, with or without effusion into serous cavities. 

(Edema is the term given to local effusions into the areolar tissue. 
Effusions into the several cavities of the body are respectively called 
hydrocephalus, hydrorachis, hydrothorax, hydrcpericardium, ascites, 
ovarian dropsy, hydrocele. 

Varieties. — The varieties of dropsy are dependent upon their cause. 
Thus there exist (1) mechanical dropsy, (2) dropsy from debility, (3) 



HYDROPS. 271 

febrile and renal dropsy, (4) pulmonary dropsy, (5) cardiac dropsy, 
(6) hepatic dropsy. 

Symptoms. — The disease generally first shows itself towards evening 
with a swelling of the feet and ankles, which disappears after lying down. 
By degrees the swelling becomes permanent, ascends, and successively 
affects the thighs, the integuments of the trunk, the penis and scrotum, 
or the labia. In extreme cases the dropsical effusion extends to the 
upper extremities, and to the integuments of the chest, neck, and face. 
Effusion into one or more of the serous cavities almost invariably accom- 
panies such a condition. The parts occupied by the fluid pit on pressure 
with the finger. Except in renal dropsy, the urine is scanty, high- 
coloured, and deposits lithates. The skin is pallid like marble, cold, and 
dry, and when the effusion is great, it becomes tense and shining. By- 
and-by it gives way at several points, the water oozes out, and the con- 
tiguous skin becomes red and excoriated ; sometimes it is raided up into 
small blisters, sometimes it sloughs. Dyspnoea, palpitation, flatulence, 
and drowsiness are commonly associated with diopsy. 

Cause. — With a view to prognosis and treatment it is of the utmost 
importance to ascertain the cause of the dropsy, and thus to distinguish 
the different varieties of the disease. In some cases the acumen of the 
physician will be severely tested- The following are the chief points to 
be attended to : — 1. If the dropsy be purely local or asymmetrical, it is 
dependent upon mechanical obstruction of a particular large vein — e.g., 
oedema of head, neck, and upper extremities may be due to an aneu- 
rismal or other tumour pressing against the descending cava. (Edema 
of the leg may arise from the pressure of a cancerous mass in the pelvis 
upon the corresponding iliac vein. 2. Dropsy from debility will be 
recognised by attention to the previous history of the patient. There is 
no history of rheumatism or scarlet fever, and there are no present 
symptoms of organic disease of either of the great organs. There may 
be a soft bruit at the base of the heart ; but we shall have no great 
difficulty in assigning this to its proper cause — anaemia. 3. Acute or 
febrile dropsy is known by its sudden appearance following exposure to 
cold, as when a person, after violent exercise and in a profuse perspira- 
tion, falls asleep on the cold damp ground ; or when, during recovery 
from scarlatina, the action of the skin is checked by exposure to cold, 
wind, or rain. This variety has its origin in severe congestion of the 
kidupys, as indicated by the scanty, albuminous, bloody, or coffee- 
coloured urine. Chronic forms of renal dropsy will also be indicated by 
the condition of the urine, and the absence of severe cardiac and pulmo- 
nary symptoms. In these grave diseases the urine is pale, like whey, 
highly albuminous, and usually deposits a slight cloud composed of casts 
of the uriniferous tubules. (See acute and chronic nephritis.) 4. Pul- 
monary dropsy generally follows an acute attack of general bronchitis 
in one who has long suffered from emphysema. In other cases we may 
detect consolidation of the lung from cancer or tubercle, or the lungs 
themselves may be (edematous from local debility of their structure. 
5. Cardiac dropsy is most commonly due to disease of the valves of the 



212 DEOPSY. 

heart allowing of regurgitation of the blood, and resulting in obstruc- 
tion to the entrance of venous blood into the lungs, and consequent con- 
gestion of the venous system. Occasionally the cause lies in a fatty 
heart. Abnormal heart-tounds and a feeble, intermittent pulse point 
out these conditions. 6. Hepatic dropsy is readily known from that 
arising from other causes, by the history of the patient, the presence of 
excessive ascites before the appearance of swelling in the legs, the condi- 
tion of the liver, the absence of swelling from the upper parts of the 
body, and scanty bilious urine loaded with lithates and usually free from 
albumen. (See Cirrhosis, Cancer of the Liver.) 

Prognosis. — Favourable, excepting when dependent on organic disease 
of long standing, and great severity. 

Treatment. — Indications. I. To remove the cause. II. To di- 
minish the quantity of the fluid. III. To relieve urgent symptoms by 
its discharge. 

I. In inflammatory dropsy and that dependent on febrile action, the 
remedies for inflammation and fever are indicated ; in dropsy dependent 
on debility, tomes or stimulants according to the degree of the debility; 
in dropsy dependent on venous congestion, moderate depletion to relieve 
the vessels, and regulated pressure to afford support ; in congestive 
dropsy dependent on organic disease, medicines directed to relieve the 
disease which causes the congestion ; and in dropsy from organic disease 
leading to an alteration in the constituent principles of the blood, a treat- 
ment appropriate to the disease in question. 

II. The quantity of the effusion may be lessened by remedies which 
increase the secretions of the skin, kidneys, and bowels — by sudoriflcs, 
diuretics, and purgatives adapted to the state of the patient. Among 
sudoriflcs, the salines are to be preferred, such as nitrate of potass, ace- 
tate of ammonia, &c. ; among diuretics, the salts of potass or soda, in 
combination with some of the diuretic infusions or decoctions ; and among 
purgatives, the saline aperients, the compound jalap powder in doses of 
irom gr. xx. to gr. lx., and the extract of elaterium in doses of from 
gr. J to gr. i. The doses and strength of the several remedies must be 
legulated by the state of the patient, the sudoriflcs and diuietics belong- 
ing to the class of depressants being preferred in inflammatory and 
febrile dropsy, and in comparatively vigorous states of the system ; and 
sudoriflcs and diuretics belonging to the class of stimulants in states of 
debility. The saline purgatives will be more appropriate in the hitter 
form, and more drastic purgatives in the former. Cardiac, hepatic, 
and renal dropsy also requiie modifications of treatment, and remedies 
adapted to the primary disease. (See the Diseases of the Heart, Liver, 
and Kidney.) 

III. When dropsical accumulations interfere mechanically with the 
functions of surrounding parts, it may be necessary to resort to opera- 
tions in order to discharge the fluid, viz. acupuncture, in anasarca threat- 
ening to discharge itself by vesication, or ulceration of the skin ; para- 
centesis abdominis, in ascites, in hydrothorax paracentesis thoracis ; in 
hydrocele tapping, followed by stimulant injections to effect a radical cure. 






( 273 ) 

ERYSIPELAS— ST. ANTHONY'S FIRE. 

Definition. — A contagious malady, epidemic at certain seasons, con- 
sisting in an inflammation of the skin, or of the skin and cellular tissue, 
spreading from a single centre over a greater or less extent of surface, 
and subsiding, or disappearing in one part as it extends to another. 

Varieties. — 1. Idiopathic erysipelas. 2. Traumatic erysipelas. 

1. Idiopathic Erysipelas. 

Symptoms. — The disease usually sets in with rigors, and other symp- 
toms of pyrexia ; with confusion of intellect, and sometimes with deli- 
rium or coma. There is nausea, and, in some cases, vomiting ; in others 
diarrhoea ; the tongue is moist, and covered with an uniform white fur ; 
and the pulse is frequent, quick, full, and compressible. After a vari- 
able interval of a few hours, or of one or two days, a red spot, accompa- 
nied by more or less swelling, appears on the skin. From this centre an 
inflammatory blush of a rosy, bright scarlet or dusky red colour spreads 
more or less rapidly, fading away into the healthy skin. The inflam- 
matory area rapidly extends, and the affected and contiguous portions of 
the integuments become more or less oedematoi'S. As the redness ex- 
tends, it disappears from, or gradually subsides, in the parts first occu- 
pied. After a longer or shorter time the inflammation usually termi- 
nates in desquamation of the cuticle, or in the formation of vesicles of 
variable size, containing a yellowish serum or lymph. The fever is in 
proportion to the extent of the disease, and only declines after it has 
ceased to spread, when, in favourable cases, the patient rapidly regains 
appetite and strength. In unfavourable cases, the fever assumes the 
typhous character, passes through the several stages, and displays many 
ot the symptoms described under ' Typhus Fever ' (see page 288), and 
the patient sinks comatose or exhausted from the fifth to the tenth day ; 
rarely so late as the fourteenth or twenty-first. 

Terminations. — 1. Resolution (erysipelas mitius). 2. Vesication 
and desquamation of the cuticle. 3. (Edema {erysipelas cedematodes). 
4. Inflammation of cellular membrane (erysipelas phlegmonodes), with 
consequent suppuration, or gangrene (erysipelas gangrenosum). 5. 
Pyaemia. 6. The disease sometimes suddenly leaves one part of the 
surface, and attacks a distant part (erysipelas erraticum). 7. Inflam- 
mation of the brain and its membranes. 8. Inflammation and sup- 
puration of the mucous membrane of portions of the intestinal canal. 
9. Inflammatory oedema of the glottis producing suffocation. 

Erysipelas of the face (erysipelas faciei) is by far the most common 
form. It commonly begins on the nose, and thence gradually extends 
over the entire face, causing great swelling of the nose and eyelids, and, 
in extreme cases, giving rise to horrible disfiguration. Sometimes it de- 
scends and spreads over the neck and trunk, but more commonly attacks 
the scalp. In its passage over the head, the membranes of the brain 
are often more or less affected, and there is acute headache, accompanied 



274 ERYSIPELAS. 

sometimes by delirium of the violent or of the muttering kind, and 
occasionally terminating in coma. From the head it generally extends 
down the back, and sometimes affects the membranes of the spinal cord. 
In severe cases, traces of the affection of the membranes of the brain and 
spinal cord remain for some time, and are shown by mental excitement, 
and by numbness and spasmodic twitchings of the extremities. Ery- 
sipelas of the head and face is generally accompanied by more or less 
inflammation and redness of the throat, and in rare instances it proves 
fatal by inducing serous effusion into the submucous tissue of the glottis 
and epiglottis. 

Pathology. — A special inflammation of the blood-vessels and lym- 
phatics of the skin, which may terminate in resolution or in the for- 
mation of pus within these vessels. In the latter case symptoms of 
pyaemia may appear. 

Morbid Anatomy. — Inflammatory or purulent deposits may be 
found in the viscera, especially the lungs ; and upon the serous and 
mucous membranes. 

Causes. — Predisposing . A full plethoric habit ; constitutional pe- 
culiarity ; previous affections of the same nature. The adult age : de- 
bilitating diseases, such as dropsy, renal dropsy especially, fever, or the 
febrile exanthemata. Exciting. — Contagion; cold; excessive heat, or 
vicissitudes of temperature ; exposure to the rays of the sun ; abuse of 
fermented liquors; suppressed evacuations; the presence of irritating 
matter in the alimentary canal ; wounds or local inflammation of the 
common kind occurring in certain constitutions, in certain seasons, and 
in places where the disease already exists. It is often epidemic during 
spring and autumn, frequently prevailing in hospitals, gaols, and other 
crowded situations ; and it is a frequent concomitant of puerperal fever. 

Diagnosis. — From erythema by the duskier blush, pain, and swell- 
ing, and by the presence of severe pyrexia. Erythema nodosum does 
not tend to diffuse itself, and is never accompanied by pyrexia. Acute 
eczema is liable to be confounded with erysipelas. It is distinguished 
by the presence of a minute vesicular eruption. 

Prognosis. — Favourable. The fever purely inflammatory ; a rosy 
or bright scarlet colour of the diseased skin ; not extending over a large 
surface ; no vesications; the febrile symptoms diminishing with the dis- 
appearance of the blush ; and this, soon after, assuming a yellowish hue, 
with an abatement of the swelling. The adult age. Unfavourable. — 
The fever assuming the typhous form ; the inflammation becoming of a 
dark rose-colour; its sudden recession from the surface, and invasion of 
an internal part ; its extension over a large surface without leaving the 
part it first occupied ; livid vesications ; weak, rapid, irregular pulse ; 
great prostration of strength ; early appearance of coma ; the disease 
being epidemic ; original or acquired debility ; complication of the disease 
with dropsy, jaundice, or other affections originating in organic disease. 
Infancy and old age. 



EKYSIPELAS. 275 

Contagion — Infection. — The disease chiefly spreads by contact ; 
it is doubtful whether it is ever propagated through the air. It may 
be inoculated, and it is conveyed by fomites. It may attack the same 
person several times, and may coexist with other severe diseases: its 
period of incubation from a few hours to two or three weeks. It is an 
epidemic malady, and rages in some years with extreme violence. 

Mortality. — The deaths in the metropolis, in a million of persons 
of all ages, vary from 110 to 260, and average 160. The rate of mor- 
tality among persons attacked varies with the severity of the epidemic, 
from one in three to one in ten ; or it is even less. 

Treatment. — Indications. I. To subdue inflammation, and pro- 
mote salutary changes in the part affected. 

II. To support the strength of the patient. 

III. To obviate the tendency to a determination to the head or other 
important organs. 

I. The general inflammatory action will be greatly relieved by free 
excretion from the alimentary canal, the kidneys, and the skin. A full 
dose of compound jalap powder may be given once or oftener, and fol- 
lowed by repeated doses of acetate of ammonia (Jss. P. B.), combined 
with gr. v to gr. x of carbonate of ammonia. To subdue the topical 
inflammation, we may apply warm fomentations, such as decoction of 
poppy heads. The part may previously be rubbed over with solid ni- 
trate of silver. Light bandaging is of great service where it can be 
applied. In every case the inflamed skin should be carefully covered 
from exposure to the air, and where hot flannels or poultices cannot be 
conveniently applied, we may use flour, starch powder, carbonate of 
zinc, or simply cotton wool. A mixture of two parts of collodion and 
one of castor oil forms a very complete protection to the inflamed skin. 
It is elastic, and by its contraction gives the required support to the 
swollen parts. It should be thickly painted on by means of a cameFs- 
hair brush. 

II. As the disease is essentially an adynamic one, recourse must be 
freely had to stimulants, as wine and ammonia, and to the stronger 
stimulants in persons previously accustomed to their use. These may 
be combined with opium, which is often found very serviceable, even 
when the brain is affected. 

Tincture of the perchloride of iron in TYlxxx — TY^x! doses alone, or 
in combination with quinine, every three or four hours, is a valuable 
tonic in erysipelas. If a diffusible stimulant be required, those given in 
Forms. 6, 14, may be prescribed. 

When the patient is very restless, full doses of opium must be given. 
The presence of delirium does not contraindicate the use of wine and 
quinine, if the other symptoms and the general state of the patient 
require their use. 

If the disease tends towards a typhous character, we must depend 
upon stimulants chiefly. As much as a pint of wine or brandy may 
be needed in the twenty-four hours. The latter may be given in the 



276 ERYSIPELAS. 

form of the Mistura Vini Gallici of the Pharmacopoeia. The diet 
should consist of egg emulsion, thin gruel, and beef tea. The iron may 
be continued during convalescence, or,'if need be, quinine and acid may 
be substituted. 

III. In cases of head affection with coma and delirium, much relief 
will be afforded by the application of sinapisms to the feet, mustard 
pediluvia, or a blister between the shoulders. Evaporating lotions or 
ice, may simultaneously be applied to the head. If the patient become 
very noisy and restless a full dose (gr. i — ii ) of opium will be required. 
Diseases of other internal organs must be treated by the remedies appli- 
cable to similar idiopathic diseases, taking into account the patient's 
strength. If the inflammation disappear from the surface, and attack 
an internal part by metastasis, strong stimulants, as mustard poultices, 
acetum cantharidis, or hot water, should be applied to the corresponding 
part of the surface. 

Jn phlegmonous erysipelas, the inflammation may be relieved by 
scarifications ; great tension of the integument by incisions. The in- 
cision must be free and deep if sloughing; have occurred, or matter formed ; 
we must use poultices and disinfectants continuously. 

Prophylaxis. — Cleanliness, separation, and, if practicable, isola- 
tion. Apartments which have been occupied by erysipelatous patients 
should be whitewashed and thoroughly cleansed. Two causes are active 
in propagating, if not in generating the disease in our hospitals; — the 
use of sponges in dressing wounds, and wet scrubbing of the floors of the 
wards. To avoid the first, fine tow should supply the place of sponges, 
a fresh bit being used for each patient. Sponges used in the operating 
theatre should be thoroughly washed and subsequently immersed in 
boiling water after each operation. To avoid the second cause, dry 
rubbing should be substituted for washing. The floors should never be 
wetted so long as patients are lying above them. 



2. Traumatic Erysipelas. 

In certain seasons, when idiopathic erysipelas is very prevalent, slight 
wounds and injuries are apt to be followed by erysipelatous inflamma- 
tion : and wounds or injuries of a more severe character in persons of 
unsound constitution, or in the healthy inmates of hospitals or public 
institutions where the disease already prevails, are almost uniformly 
subject to this complication. The disease often appears in lines extend- 
ing from the injured toe or finger along the leg or arm ; the lymphatic 
glands become affected, and those of the axilla, in particular, are liable 
to diffuse inflammation and suppuration. The symptoms due to trau- 
matic erysipelas do not differ from those of idiopathic erysipelas, and 
the treatment will be the same. But in the prognosis, the original 
injury and the consequent erysipelas will have to be jointly considered, 
and as pyaemia is a more common result in this variety of the disease, 
our attention must be constantly directed to the lungs and pleura. 






CHAPTEE III. 

FEBRES— FEVERS. 

Class I. 

Non-infectious Fevers. 

I. Febricula. .... Simple Fever (see p. 265). 

II. Febris Intermittens . Ague. 

III. Febris Remittens . Remittent Fever. 

IV, Febris Icterodes . . Yellow Fever. 

Class II. 

Infectious Fevers. 

I. Typhus Epidemic Continued Fever. 

II. Enteric or Typhoid . Endemic Continued Fever. 

III. Relapsing Fever . . Famine Fever. 

IV. The Exanthemata. (See Chapter IV.) 

General Observations on Non-infectious Fevers. 

Febricula has been already described. It is caused by some derange- 
ment of the functions of the body. Ague, remittent and yellow 
fevers, are endemic, and originate in one common external cause; viz., 
marsh miasma. Apart from their common origin, they have so many 
other resemblances that we may safely assume them to be varieties of 
one and the same disease, the differences being due to the variation in 
power or intensity of the primary or exciting cause. Thus, if the marsh 
poison introduced into the system be small in amount, the body suffers 
only occasionally, a febrile attack coming on every second or third day, 
or after longer intervals. If the dose be larger, the interval between 
the paroxysms are shorter and are no longer intermissions — intervals of 
freedom from fever, — but mere remissions of a more intense febrile con- 
dition. If, again, the system receive a still more powerful dose of the 
paludal poison, the fever becomes continuous, and those internal organs 
which, in the former cases, were comparatively little affected, are now 
fearfully deranged. Between intermittent and remittent fevers, and 
between remittent and yellow fevers, there are, in truth, no lines of 
demarcation ; they run into each other most completely. 

Given a certain source of paludal miasma, the intensity of the fever 
generated by it will be, cccteris paribus, in proportion to the external 
temperature. In the Arctic regions these fevers are unknown, and the 



Z<y INTERMITTENT FEYER. 

mildest variety of them rarely passes beyond the fifty-sixth degree of 
latitude. In the latitude of London, and five degrees south of it, the 
disease assumes the intermittent type ; south of this line it becomes re- 
mittent ; still nearer the equator, remittent is not to be distinguished 
from yellow fever. 

These fevers are of great interest and importance to a nation which 
has soldiers and sailors scattered over the whole of the habitable globe, 
and serving under circumstances of great exposure, fatigue, and priva- 
tion. Remittent fever, though by no means unknown in England, as- 
sumes in some of our dependencies a character of great malignity, rival- 
ling, and even surpassing, the oriental plague itself in the violence of its 
attack and the mortality it occasions. The records of our army serving 
abroad, show that even if we include stations in which the disease is 
unknown, or of very rare occurrence, one soldier in every eight is at- 
tacked by remittent fever, of which number at least one eighth die. 
If, however, we exclude from our calculation the stations in which re- 
mittent fever is wholly or nearly unknown, the attacks exceed 1 in 7, 
and the deaths amount to between a seventh and an eighth of those at- 
tacked. The mortality, however, varies very widely in different places. 
In the Tennaserim provinces, it is as low as 1 in 27, at Bombay 1 in 25, 
at Malta 1 in 24 ; while it destroys 2 in 11 in Ceylon, 4 in 11 in the 
Bermudas, and 1 in 2 in Western Africa, on which fatal coast the attacks 
are nearly equal to the number of soldiers. 

The disease sometimes derives its title from the places in which it pre- 
vails. At other times from some prominent symptom. Thus we have 
the Walcheren, Levant, and Mediterranean fever ; the jungle and hill 
fever of the East Indies ; the lake-fever of America ; the Bulam, Sierra 
Leone, African, and Bengal fever ; the gall -fever of the Netherlands ; the 
bilious remittent of the West Indies ; and the yellow fever of Jamaica, 
Gibraltar, and the Bermudas. 

The yellow fever, and the more severe forms of the disease, require 
for their development the combination of marsh effluvia and a tempera- 
ture exceeding 75° Fahr. The low-lying spots near the coast are its 
favourite haunts, and it is believed to disappear at an elevation of about 
2500 feet above the level of the sea. 



FEBRIS INTERMITTENS— AGUE. 

Synonyms. — Intermittent fever. Fever and ague. 

Definition. — A fever caused by marsh miasma, and consisting of 
paroxysms,* occurring at regular intervals with perfect intermissions. 

Varieties. — 1. The Quotidian; a paroxysm once in 24 hours. 2. 

* The period between the end of one paroxysm and the beginning of the next 
is called the intermission : the period occupied by one paroxysm and one inter- 
mission is called the interval. 



AGUE. 278 

The Tertian ; a paroxysm once in 48 hours. 3. The Quartan ; a 
paroxysm once in 72 hours.* 

Symptoms. — Ague sometimes attacks a patient suddenly ; but in 
most cases it is ushered in by symptoms similar to those which mark 
the onset of continued fever ; and it is not till after several days, or 
even one or two weeks, that it assumes its perfect form. It is then re- 
cognised by the occurrence, at regular intervals, of a paroxysm consist- 
ing of three stages — a cold, a hot, and a sweating stage — following each 
other with great regularity. The Cold Stage. — Languor and listless- 
ness; sighing, yawning, and stretching; pallor; blueness of the ears, 
lips, and nails : shrinking of the features ; and constriction of the skin 
of the wh\ple body {goose-skin or cutis anserina) ; a sense of oppression 
at the pit of the stomach ; violent shiverings, chattering of the teeth, 
and trembling of the limbs ; pain in the head, back, and loins ; the 
secretions diminished ; the urine scanty, pale, and limpid ; the pulse 
small, frequent, and sometimes irregular ; and the respiration short and 
anxious. These symptoms terminate at length in universal and convul- 
sive shaking. The Hot Stage. — The heat of the body gradually re- 
turns ; at first irregularly by transient flushes, which are succeeded by 
a steady, dry, burning heat, rising much above the natural standard. 
The skin is now swollen, red, and pungent, the face flushed, and the 
eyes injected. The sensibility becomes preternatu rally acute, and the 
aching of the head is exchanged for acute pain. The pulse becomes 
quick, full, and hard ; there is great thirst ; the urine is scanty and 
high-coloured. The Sweating Stage. — At length a moisture breaks out 
on the face and neck, which soon becomes a universal and equable per- 
spiration. The heat now descends to its usual standard; the pulse re- 
sumes its wonted frequency and usual character ; the respiration becomes 
free and tranquil ; the urine deposits a sediment ; and the patient is for 
a time restored to health. 

Occasional Symptoms. — In the cold stage, coma or apoplexy ; in 
the hot stage, delirium. Convulsions, syncope, rigid spasms, neuralgia, 
jaundice, dysentery, and petechias on the skin, have also been recorded. 
In ague districts, and in persons who have previously had ague, many 
diseases assume the intermittent character. Of these, hemicrania, or 
intermittent face-ache, or brow-ague, is the most common. 

Duration of the Paroxysm, &c. — The quotidian is most 

* Also, 1. The double quotidian, haviDg two paroxysms every day. 2. The 
double tertian, having a paroxysm every day, those ot the alternate days being 
of equal duration and intensity. 3. The triple tertian, in which two paroxysms 
occur on one day, and one on the other. 4. The duplicated tertian, which re- 
turns twice on each alternate day. 5. The double quartan, in which a paroxysm 
occurs on the day succeeding that of the regular quartan, so that there is a per- 
fect intermission only on the third day. 6. The duplicated quartan, in which 
two paroxysms occur on the day of attack, with two days of intermission. 
7. The triple quartan, in which a slight paroxysm occurs on each of the usual 
days of intermission. These forms of ague, as well as those which have longer 
intervals (such as five, six, seven, eight, nine, or ten days, a month, or a year), 
and are called erratics, require the same treatment as the three primary types. 



280 INTERMITTENT FEVER. 

common in spring, and generally occurs in the morning : usual duration 
upwards of twelve hours. The tertian is a common type ; it occurs both 
in spring and autumn, and commences at noon : usual duration about 
eight hours. The quartan is a rare type ; it is more severe, occurs in 
autumn, and generally begins in the afternoon: usual duration about 
six hours. The qua. tan has the longest cold stage, the tertian the longest 
hot stage. 

The type is subject to change : tertians and quartans become quoti- 
dians, and quotidians remittents; or they pass into continue! fever. 

The paroxysms of ague are sometimes obscure ( dumb ague\ or in- 
complete, or inverted ; sometimes they are irregular or erratic, some- 
times partial, or affecting only a portion of the body. 

Period of Incubation. — From a few hours to several days, weeks, 
or months. Average duration, from ten days to a fortnight. 

Pathology. — During the cold stage, th<» blood leaves the capillaries 
of the surface, and collects in the deep-seated parts ; there is congestion 
in the head, chest, and abdomen ; and the vascular spongy organs, espe- 
cially the spleen and liver, are liable to suffer, and if the disease last for 
any length of time, become large and hard (ague-cake). 

Terminations. — In chronic enlargement, with induration, soften- 
ing, or suppuration of the liver and spleeu ; followed by ascites and 
anasarca ; in fatal dysentery ; in apoplexy ; in fever of the remittent 
or continued type. In leucocythemia. (See p. 262.) 

Causes. 1. Predisposing. Debility; intemperance; cold and mois- 
ture ; middle age ; male sex ; a previous attack. 2. Exciting. — Marsh 
miasma, or the effluvia from decomposing vegetable matter. Also the 
effluvia from certain soils, impregnated with moisture, but apparently 
free from vegetable decomposition. The danger is greatly increased 
by exposure to these effluvia at night. 

Diagnosis. — Ague can only be confounded with hectic fever, and 
rigors, arising from some local cause, such as the passage of a gall-stone, 
the introduction of a catheter, or, more commonly, the formation of pus 
in some of the internal organs. In every doubtful case we must there- 
fore search for a loc \\ cause. 

Prognosis. — Favourable. In cold and temperate climates. The 
paroxysms of short duration, regular in their recurrence, and the inter- 
missions quite tree from fever ; the postponement of the paroxysms : the 
short previous duration of the malady ; the quotidian and tertian types : 
an eruption on the lips. — Unfavourable. The disease of long standing ; 
the paroxysms anticipating their usual time ; being strongly marked, of 
long continuance, and attended with anxiety and delirium ; a feverish 
state during the intermission ; complication with other diseases ; enlarge- 
ment of the liver and spleen ; the quartan type. 

Treatment. — In the Paroxysm. During the first or cold stage. 



AGUE. 281 

The patient should be put into a warm bed, and warmth restored as 
promptly as possible by a hot brick or bottle to the feet, bags of hot 
bran or salt to the pit of the stomach, or a warm, hot-air, or vapour 
bath, aided by friction of the back and limbs, and the administration of 
warm tea, or weak wine and water. 

During the second, or hot stage, cool air, cooling drinks, and sponging 
with tepid water. 

During the third or sweating stage, the patient should be protected 
from cold draughts of air, and when the fit is over, he should wash in 
warm water, be thoioughly dried, return to bed, and be allowed to 
sleep ; or be supplied with dry, warm clothing. The patient may now 
take a meal of nourishing food, and if much exhausted, a little warm 
brandy, or wine and water. 

In the intermission. Some remedy which experience has shown to 
possess.the power of preventing the return of the intermittent paroxysms 
should be administered : of these quinine and arsenic are the most efficient. 

Cinchona bark, or its active principle quinine, and arsenic, are specific 
remedies in ague, and other intermittent disorders. Quinine is the more 
fitting remedy; it may be given in pill, or in mixture with excess of 
acid, in doses oi' five, ten, twenty, or even thirty grains daily. 

Arsenic may be given in the form of liquor arsenicalis in doses of 
TY\v, gradually increased to lY\x or ir^xx, either alone or in combination 
with laudanum, every four hours during the period of intermission. 
Its effect must be carefully watched. 

Previous to the administration of the specific remedy, the bowels 
should be freely opened by a brisk aperient (Form. 256). 

The treatment of hemicrania, of brow-ague, and of those intermittent 
maladies known as masked ague, e. g. intermittent vomiting, diarrhoea, 
&c, is that of ague itself. 

Remedies. — In the paroxysm, or before it. Emetics, given just 
before the fit, to prevent its occurrence, or during the cold stage, to 
hasten the appi oach of the hot fit. Laudanum, either alone or with 
aether (one drachm of each), may be given with great advantage, before 
the cold fit, or with more effect during the hot stage. 

In the intermission. — Vegetable and mineral tonics (Form. 145) and 
an occasional cholagogue purgative (Form. 275). 

Prophylaxis. — Avoidance of the air of early morning and evening, 
and of sleeping places near the ground. The choice of a dwelling on 
hilly ground, or in such a situation that the malaria may be intercepted 
by an intervening wood or broad surface of water. Warm and nourish- 
ing food before labour in malarious districts. Sailors should not sleep 
on land in such districts; and ships should be stationed at a distance of 
two or three miles from unhealthy coasts. Small doses of quinine two 
or three times a day. Thorough drainage. 

Treatment of the Seqtjeue of Ague. — Such as anaemia, and 

enlargement of the spleen and liver, and chronic dysentery, will be that 
recommended under these diseases. 



( 282 ) 



FEBRIS REMITTENS— - REMITTENT FEVER. 

SYNONYMS. — Bilious remittent, remittent marsh, or paludal, fever. 

Definition. — A non-infectious fever with distinct exacerbations of 
variable duration and severity, but with no complete intermission. 

Symptoms. — The premonitory symptoms are those of ague, but the 
sensation of coldness is not so prominent a symptom. There is not 
always distinct rigor. The head symptoms are more severe ; the coun- 
tenance is flushed ; and there is intense throbbing headache, and occa- 
sionally violent delirium. Tenderness of the epigastric and right hypo- 
chondriac regions, nausea, and bilious vomiting, with torpid bowels and 
scanty urine, are among the early symptoms. The alvine discharges 
are dark, often greenish, and very offensive ; and there is considerable 
pyrexia and a dirty brownish tongue. The pulse is very variable in 
force and volume. 

The fever subsides as the skin moistens and sweat appears ; and thus 
a remission or moderation of the disease occurs. The patient remains in 
a state of mild fever, accompanied by giddiness and lassitude for about 
two hoars, when the febrile symptoms recur, and slowly increase until 
they attain their former intensity, or exceed it. Paroxysms and remis- 
sions follow each other in regular succession for 7, 14, 21, or 28 days ; 
at the end of either of which periods a profuse perspiration may termi- 
nate the attack. 

In severe forms of the disease the paroxysms are more intense, the re- 
missions shorter and less marked, the skin becomes yellow and pungent, 
the tongue covered with a slimy yellow mucus, the stools foetid ; the 
strength sinks, the pulse becomes thready, sordes form on the teeth, ten- 
dinous spasms are noticed, and stupor supervenes, passing into fatal coma. 
This more severe form is not distinguishable from yellow fever. 

Duration". — From five or six days, to four or five weeks. Usual du- 
ration about a fortnight. 

Causes. — Those of intermittent fever. The disease is most common 
and severe in hot climates ; in England it is rare, but this cannot be said 
of temperate latitudes generally. 

Diagnosis. — From continued fever by the recurrence of intervals or 
comparative freedom from febrile excitement. 

Prognosis. — Favourable, in proportion as the remissions are more 
distinct. Unfavourable, when the fever assumes the continued type, 
and in proportion to the suppression of the hepatic and renal secretions. 

Treatment. — The worst forms must be treated in the manner re- 
commended for yellow fever. As soon as the intermissions become w T ell 
marked, the treatment for intermittent fever must be adopted. Quinine 
or arsenic may then be given, as in ague, during the remission. 

Sequels. — Diarrhoea and dysentery. — Enlargement of the liver and 
spleen, and the anaemic state known as leucocythcemia. (See p. 262.) 



( 283 ) 

DENGUE OR DANDY FEVER. 

Under this and other names a febrile affection, " sui generis " has been 
described by several Indian physicians. 

Definition. — A remittent fever, characterised by severe arthritic 
pains and the eruption of an evanescent scailet or morbilloid rash or 
efflorescence, fiist upon the palms of the hands and rapidly spreading 
thence over the rest of the body. 

Symptoms. — Resemble those of a common cold, viz., lassitude, heavi- 
ness of the eyes, slight vertigo, a sensation of creeping cold down the 
back. Sometimes there are no premonitory symptoms, and the patient 
wakes out of sleep with great pain in the head, loins, and all the joints 
both small and large. Occasionally, the accession of the symptoms is so 
sudden that the individual is taken with arthritic pains and stiffness while 
walking in the street. 

The hands in particular become stiff and swollen, the eyes watery, 
the conjunctivae suffused, and the whole countenance bloated, swollen, and 
flushed. There is intense aching of the eyeballs, and they feel too large 
for their sockets. The pulse is full, strong, and about 100. The tongue 
is moist and coated, and the margins red or scarlet. The skin is dry and 
hot. There is nausea and anorexia and the bowels are usually confined. 
The pains shift rapidly from one joint to another, are excruciating, and 
there is great debility and restlessness. 

Towards the end of 24 hours the headache and flushing of the face 
begin to decrease, and the pains lose their acuteness and assume a dull, 
aching character. Perspiration now appears, and there is great prostra- 
tion of strength. Extreme languor continues during the whole period of 
remission. About the end of the third day the febrile symptoms return, 
and sometimes even with increased severity. The skin is hot and turgid, 
and red blotches like measles or scarlatina, often elevated and rough, 
appear upon the swollen hands and feet, and produce distressing tingling 
and itching. During the next 24 hours this efflorescence gradually 
spreads over the rest of the cutaneous surface and then dies away the 
following day, and is followed by desquamation. 

The pains generally, but not always, begin now to subside, but the 
disease does not usually leave the patient until he has suffei ed a second 
or even a third relapse of fever. 

Duration and Sequelae. — Relapses are often numerous, and the 
disease may continue for several weeks, and be attended with much de- 
bility and neuralgic pains of the joints. Cachexia, jaundice, with sub- 
acute hepatitis, hsemorrhoides, and neuralgia, are fiequent consequences 
of this disease. 

Distribution. — This disease has prevailed epidemically in the West 
Indian Islands, and the southern parts of India. 

Cause. — Predisposing. Heat, moisture, and stagnation of the air. 
Exciting. Derangement of the digestive organs. 



284 FIBRIS ICTERODES. 

Pathology. — Gastric and biliary derangement appear to be the con- 
ditions out of which the disease arises, and in its leading features it bears 
a strong resemblance to derangement of the digestive apparatus, which, 
results in urticaria. The alvine dejections are of a dark-green colour, or 
even black, scanty and offensive. 

Prognosis. — Usually favourable. But the debility is sometimes so 
great during the remission as to result in sudden death. 

Treatment. — At the onset, emetics, and free purgation by means 
of calomel and colocynth, followed by saline aperients. During the re- 
mission, quinine and the mineral acids. 



FEBRIS ICTERODES— YELLOW FEVER. 

Synonyms. — Typhus or synochus icterodes ; Febris remittens gravior 
cum ictero ; Bilious remittent of warm climates ; Bulam fever; Mai 
de Siam ; Vomito negro ; Vomito prieto ; Coup de Bane ; &c. 

Definition. — A remittent fever accompanied by yellowness of the 
skin, and vomiting of a black or dark-brown fluid. (The disease as- 
sumes, in different epidemics, and often in the same epidemic, the several 
types of continued, remittent, and intermittent fever, and appears in every 
degree of severity, from simple ephemeral fever up to the worst forms 
of the disease. Yellowness of skin and black vomit are characteristics of 
the fever in its most marked form.) 

Symptoms. — The disease usually sets in with lassitude, listlessness, 
faintness, and giddiness, with frequent chills, acute pains in the back and 
limbs, pains in the head and eyeballs, a flushed face, an anxious expres- 
sion of countenance, an injected, brilliant, and watery eye, and a hot, 
dry, and harsh skin. The mouth is clammy ; the tongue generally white 
and moist, or watery, furred at the centre, and red at the tip and edges : 
and the patient is usually very thirsty. The pulse is increased in fre- 
quency, full, and hard ; the respiration hurried, and interrupted by fre- 
quent sighs ; there is great tenderness of the epigastrium, with extreme 
irritability of the stomach, and vomiting of the ingesta mixed with a 
glairy fluid. The bowels are confined, and the motions often clay- 
coloured. The urine is sometimes tinged with bile. 

After these symptoms have continued, with increasing severity, from 
a few hours to three days or more, a marked remission takes place, and 
the symptoms, as well as the sensations of the patient, continue for several 
hours so much improved as to excite sanguine hopes of recovery. Some- 
times the recovery of the patient dates from this remission, but more 
frequently the improvement is delusive. The febrile symptoms return, 
accompanied by increased debility ; a small and frequent pulse ; a cold 
and clammy skin ; shrinking of the features ; a dry tongue, covered with 
a brown or black fur ; increased tenderness of the epigastrium, with an 



YELLOW FEVER. 285 

acrid burning sensation extending to the gullet, with extreme irritability 
of the stomach, and vomiting of all ingesta. 

After a further interval of twenty-four or forty -eight hours, and some- 
times earlier, the more characteristic symptoms appear: viz., jaundice ; 
incessant hiccup, vomiting of inky-black fluid ; a feeble, irregular pulse; 
accumulation of sordes upon the tongue and teeth ; petechias ; dark and 
gelatinous stools ; haemorrhage from the mouth, ears, nostrils, or bowels. 
In fatal cases, death may occur as early as the third or fourth day; it 
usually happens about the eleventh day, but occasionally still later. 

Such is the usual course of this disease. But the symptoms and 
mode of termination vary greatly in different countries, in different epi- 
demics, and even in the same epidemic. The following are some of the 
varieties : — a. Sudden coma and death in convulsions. b. Sudden 
seizure with black vomit, and death in a few hours, c. Intense pain 
and tenderness in the epigastrium, incessant vomiting, and death from 
exhaustion, d. Great anxiety and restlessness, with a clean tongue, and 
nearly natural pulse, followed after a time by black vomit and fatal ex- 
haustion. Death may be sudden, the sequel of a quiet sleep, and it is 
sometimes preceded by acute pain and strong convulsions. 

Sequels. — Organic diseases of the lungs, liver, spleen, or other in- 
ternal viscera. Obstinate dysentery. Slow and tedious convalescence. 

Causes. — Predisposing. A continued temperature of not less than 
75° to 80° Fahr. The latter end of summer and beginning of autumn. 
The climate of the West Indies, of the south of Spain, of the seaports of 
intertropical America, of Mexico, and of parts of Africa. It occurs more 
or less frequently, and with greater or less severity, in the West Indian 
Islands, at the Havana, at Vera Cruz, at New Orleans, Mobile, Charles- 
ton, Baltimore, Philadelphia, and New York, at Gibraltar, and Barce- 
lona. Male sex ; intemperance ; depressing passions ; all the predis- 
posing causes of common continued fever ; especially imprudent exposure 
to night air. Recent arrival at the place where the disease exists. Want 
of protection by a previous attack. Exciting. — Marsh miasma, and de- 
composition of vegetable matter. The disease is most common in swamps 
at the mouth of rivers, in the low-lying parts of crowded cities, and in 
ships laden with vegetable produce, or kept in a damp and filthy state. 

Period of Incubation. — Less than 10 days. 

Morbid Anatomy. — General yellowness of the skin, sometimes in- 
terspersed with blue or livid spots ; the brain and its membranes gene- 
rally healthy, and rarely presenting effusion of serum or blood ; red, livid, 
or dark-black spots and patches on the mucous membrane of the stomach, 
and in its cavity with an inky black fluid (black vomit). The intestinal 
canal contains the same black fluid. The intestinal mucous membrane 
often shows patches of a brown or blackish colour, but no ulcers as in 
typhoid fever. The gullet is sometimes found inflamed and abraded ; 
the liver is either greatly congested, or small and anaemic ; the bladder 
is contracted and sometimes inflamed. In some epidemics blood has been 
effused into the structure of the muscles. 



286 FEBRIS ICTERODES. 

Diagnosis. — In mild cases not easily distinguished from remittent 
and enteric fevers ; but in severe cases, and in the more advanced stages, 
it is readily identified by the yellow skin and eye, and the black vomit. 

Prognosis. — Favourable. A regular and steady pulse ; a soft and 
warni skin ; a natural expression of countenance ; a moist tongue ; a free 
discharge of urine ; a distinct remission ; natural sleep of some hours' du- 
ration, undisturbed by vomiting; sudamina. — Unfavourable. Previous 
intemperance. Kecent arrival on the spot where the disease is rife. The 
early occurrence of any of the characteristic symptoms, such as yellow- 
ness of the skin, especially if it be patchy, or the black vomit ; pain in 
the back ; tenderness in the epigastrium ; acrid burning sensation in the 
stomach and oesophagus ; incessant vomiting ; deep sighing ; singultus ; 
great coldness of the surface, with a sensation of internal heat ; and an 
irregular or intermittent pulse. Recovery may take place after the ap- 
pearance of the most unfavourable symptoms, and, on the other hand, 
" it is known that in persons sitting up in bed amusing themselves, and 
apparently in a favourable state, the black vomit has suddenly appeared, 
quickly followed by death, to the utter astonishment of the medical at- 
tendants.' ? — G iUkrest. 

MORTALITY. — Very different in different epidemics. The deaths 
have amounted to 130 or 131 in 134 ; 19 in 20; 34 in 35; and 
1,265 in 1,739 ; but they have been as few as 6,684 in 16,517 ; and 
even as 1 in 8. English regiments in Gibraltar have suffered a mortality 
of 1 in 11, and 3 in 11 of the numbers attacked ; and in Bermuda of 
1 in 3, and 4 in 11. The mortality is generally greatest when the epi- 
demic is recent, and diminishes considerably in the course of time. 

Treatment. — Indications. I. To unload the stomach and insure 
the free action of the bowels. II. To take advantage of any decided re- 
mission. III. To relieve existing symptoms. 

I. The stomach should be unloaded at the very commencement by an 
emetic (Form. 220). The thorough evacuation of the whole of the in- 
testinal canal during the first two hours of the fever cannot be too much 
insisted on, and purgatives should be freely exhibited until the bowels 
have acted five or six times. 

At first we may give one, two. or three drops of croton oil, or an 
ounce of castor oil, or from ten to twenty grains of calomel, followed in 
two hours by a saline aperient Many practitioners depend mainly upon 
mercury, given not only to unload the liver and intestines, but also to 
affect the constitution. After the first aperient dose a quarter of a grain 
combined with opium may be given every two hours, and mercurial 
ointment may be simultaneously rubbed into the groins and armpits. 

II. Whenever there is a marked remission of symptoms, xx grs. of 
quinine should be administered at once, or two grains every hour. 

III. When the skin is universally hot and dry, tepid sponging and 
the affusion of cold water to the head are of the greatest advantage. 
Where there is vigour of constitution, a sudorific action of the skin may 
be induced by packing the patient in a wet sheet. When, on the con- 



INFECTIOUS FEVERS. 287 

trary, there is great coldness of surface, the warm bath, at 100° to 120° 
Fahr., and warm frictions, should be employed. Local determination 
of blood may be met by cautious local depletion or by counter-irritation. 
Bleeding fiom the aim may be resorted to at the outset of the disease 
in plethoric subjects, or where comatose symptoms are present. The 
sickness may be allayed by small quantities of arrowroot, or other de- 
mulcent fluids, effervescing draughts, ice or ice-water. The pain in 
the eyeballs and forehead may be relieved by cold to the head, the hair 
having been previously thinned, or the head shaved. Hemorrhages 
require the use of the mineral acids with bitter infusions ; or the ace- 
tate of lead in combination with opium (Form. 175) eveiy two or three 
hours. Collapse must be treated by diffusible stimulants (Form. 6). 
Extreme restlessness in the advanced stages of the disease, and when 
great debility is present, may be met by opium in doses of one or two 
grains. The diet should at first be strictly antiphlogistic ; but wine 
should be given as soon as the patient appears to require support. 

During convalescence, quinine, in a tonic effusion, such as cusparia or 
serpentaria, should be given three or four times a day. 

Prophylaxis. — Temperance, cleanliness, regular exercise, and a re- 
sidence, if possible, on a hill or rising ground. The avoidance of locali- 
ties known to be unhealthy, of exposure to the heat of the sun, of 
impure water and stale food, and of the night air, particularly when yel- 
low fever prevails. Persons of robust and plethoric habit, newly arrived 
at a place where yellow fever prevails, should carefully observe all the 
rulf-s of health; keeping the bowels open by the regular use of gentle 
aperients. The sick should be separated from the healthy ; and hospi- 
tals should be spacious, cleanly, and well ventilated. Europeans em- 
barking for tropical climates should arrange to arrive at the healthy 
feeason of the year. 



INFECTIOUS FEVERS. 
General Observations on Infectious Fevers. 

Apart from the exanthemata, modern observers have separated infec- 
tious fevers into three genera, viz., Typhus, Enteric, and Relapsing. 
These are collectively called " the continued fevers/' The generic dis- 
tinctness of relapsing fever was only established in the epidemic of 1843, 
and it was subsequent to this date that a similar distinction was recog- 
nized between typhus and enteric fevers. 

Relapsing fever is an epidemic of rare occurrence. It appears in 
times of famine, and is not marked by any cutaneous eruption, by which, 
and by the abrupt cessation of the fever, and restoration to comparative 
health for a time, it is distinguished from typhus. 

Typhus is essentially a " low " fever, being initiated by the most 
complete prostration, which increases as the disease advances, until the 
vital powers become reduced to the very lowest ebb. A characteristic 
rash and head symptoms sufficiently distinguish this fever. Gastric 



ZbO TYPHUS FEVER. 

and intestinal symptoms, on the other hand, mark the access and pro- 
gress of enteric fever, and indicate the severity of the disease. 

Typhus, like relapsing fever, is the companion of squalor and want. 
It is supposed to occur in epidemics, but we have reason to believe 
that it exists continuously to some extent and degree. Of these fevers, 
typhus is the most infectious ; enteric the least so. The mortality in 
typhus and enteric is pretty equal. That of relapsing fever is compa- 
ratively small. 



TYRHUS— EPIDEMIC CONTINUED FEVER. 

Synonyms. — From its prevailing character — Putrid, Pestilent, 
Malignant, Epidemic, ataxic, Asthenic, or Adynamic Fever: 
After a leading symptom of the disease — Brain Fever : After its 
most common external character — Eruptive, Petechial, Macu- 
lated, or Spotted Fever: After its presumed cause — Contagious, 
Infectious: and when named after the places in which it most com- 
monly prevails — Prison, Gaol, Camp, Ship, and Hospital Fevers, 
and Parish Infection. 

Definition. — A continued fever of fourteen or twenty-one days' 
duration, accompanied by extreme prostration of strength, great distur- 
bance of all the bodily and mental functions, and a strong tendency to 
cerebral complications ; and characterised, in most instances, at an early 
period of the fever, by a peculiar eruption on the skin. 

Symptoms. — The onset of continue! fever is either sudden and well 
marked, or gradual and obscure. 

In the first case, the disease is generally ushered in by a succession of 
severe shivering fits, followed by acute pain in the head, aching in the 
back and limbs, lassitude and weariness, an unsteady gait, and a disin- 
clination to exertion of mind or body. The surface is cold and pale, the 
skin contracted, and the pulse either small and weak, or full, quick, and 
very compressible. The breathing is quickened, and often interrupted 
by deep sighs. The countenance wears a dull, anxious, and confused 
expression, and sometimes closely resembles that of a person in a state of 
intoxication. The appetite fails : in some cases there is nau<ea ; the 
bowels are generally confined, and the tongue is coated with a dirty- 
white fur; ths pulse is feeble and fast, but rarely exceeds 120. 

In the second case, the symptoms are often so obscure that it is not 
easy to determine whether the patient is suffering from continued fever, 
from slight indigestion, or from a common cold. He has no well-marked 
rigors, no severe pains in the head, back, or limbs; but he is pale, lan- 
guid, weary, and drowsy, and complains of dull headache ; is disinclined 
to exertion, and incapable of applying himself to business. His appetite 
fails ; the tongue is covered with a thin white fur, the bowels are con- 
stipated, the pulse somewhat increased in frequency ; and he passes rest- 
less nights, and wakes unrefreshed. This period of uncertainty may 
last three or four days ; and the transition into a state of undoubted 



TYPHUS FEVER. 289 

fever be so gradual that it may be impossible to fix on any precise time 
at which the disease may be said to have been first present. The his- 
tory of the case, by revealing the fact of an exposure to the contagion 
of fever, is often the best aid to a correct diagnosis. 

This premonitory stage, whether the onset be sudden or gradual, 
passes more or less rapidly into fully-developed continued fever, marked 
by pungent heat of skin, frequent pulse, thirst, headache, throbbing of 
the temples, flushing of the face, suffusion of the eyes, and great rest- 
lessness and irritability. The countenance is dusky, and expresses in- 
difference and confusion of mind. Questions are answered slowly, and 
as if with difficulty, but rationally. The patient grows weaker, and 
about the fourth day is in bed, lying on his back, and unable to rise 
without assistance. If he gets any sleep it is disturbed by dreams ; he 
mutters, and often starts, and wakes unrefreshed ; but in some cases 
there is great drowsiness; in others a total absence of sleep. The 
tongue, which is at first coated with a moist dirty-white fur, or marked 
with a dry brown streak along, or on each side of, the middle line, be- 
comes uniformly covered with a dry brown coat. The urine is scanty 
and high-coloured, and is apt to accumulate in the bladder. 

About the fifth day, but varying from the fourth to the seventh, a 
diffused rubeoloid rash makes its appearance on the trunk of the body, 
being usually best developed on the chest and front of the shoulders, 
occasionally on the backs of the hands, but rarely on the face. In some 
cases and in some epidemics the rash is very faint, and the dusky skin 
is slightly freckled with a light brownish maculation. In other cases 
and in other epidemics the skin is thickly speckled and blotched with 
dusky purple petechial spots. Between these two extremes there is 
every degree of intensity. When moderately developed the rash bears 
a strong resemblance to that of measles, but it has a duskier tint. The 
spots are scarcely elevated above the surface ; their form is irregular : 
they have no defined limit, but faint away into the duskiness of the 
surrounding skin. At first they have a florid venous tint, and disap- 
pear on pressure ; but when they are a day or two old they cease to be 
prominent, become paler, and of a dirty-brown colour, and no longer 
disappear on pressure. When the number is limited the spots are 
isolated and scattered ; but wiren the rash is very copious the spots are 
loosely aggregated into irregular patches. About the seventh day deli- 
rium begins to attend the w T aking hours, and the patient mutters con- 
stantly and incoherently, or talks loudly and wildly ; and at this period 
there may be some difficulty in restraining the patient, though usually 
he is not strong enough to get out of bed. The head is intensely hot, 
and the face and neck suffused with a vivid coppery blush. Still the 
patient may be roused, and will open his mouth and fruitlessly attempt 
to protrude the parched brown tongue, which, as w r ell as the teeth, are 
blackened with sorcles. The breath and cutaneous exhalation have a 
peculiar rank cadaverous odour; the former contains free ammonia. 
The pulse ranges from 90 to 120, and varies in volume ; is always 
wanting in strength, being soft and compressible. Stupor now begins 
to alternate with delirium, and the patient lapses into a state of apathy. 

U 



290 TYPHUS FEVEE. 

He is deaf ; his expression is vacant ; the eyes filmy ; the mouth open ; 
deglutition begins to fail ; the hands are tremulous and convulsed, con- 
stantly grasping at objects in the air, or picking the bed-clothes. This 
critical condition may continue for twenty-four hours or more, and then 
the patient may begin to rally. If no improvement take place, he sinks 
into complete coma, congestion of the lungs very commonly supervenes, 
and the patient dies suffocated. The crisis occurs about the fourteenth 
day ; and if favourable, the patient falls into a sound sleep, the skin 
regains its warmth, the pulse falls, and increases in force, the skin and 
tongue begin to moisten, the patient regains consciousness, a gentle per- 
spiration sets in, the alvine and urinary secretions become more abun- 
dant, the tongue rapidly cleans, and with this improvement in the 
symptoms there is a craving for food. The pulse may fall to 60 or 
even 40. If, on the other hand, there is no amendment, the skin soon 
becomes cold and clammy, and the toes and fingers cold and blue, the 
pulse becomes more frequent, thready, and occasionally imperceptible, 
the power of deglutition is lost ; the patient lingers on awhile, and 
then dies insensible. 

Concomitant Affections. — Nervous System. — The brain is 
very soon affected in typhus, persistent headache being among the 
symptoms manifested during the first week. There is a heavy dull 
pain, accompanied by vertigo, and by moans or cries. Towards the end 
of the week it decreases, and delirium takes its place. This is some- 
times slight, being an incoherent muttering (typhomania) ; in other 
cases it is so violent as to be mistaken for acute mania ; and the patient, 
if not narrowly watched and restrained, will sometimes effect his escape 
from his attendants, and throw himself out of window, or place himself 
in circumstances of great danger. Between these two extremes there is 
every degree of intensity, proportioned to the vital power of the patient, 
acute delirium being more common in the young and robust "than in 
the aged and feeble. Wakefulness is present in most cases, and if we 
do not promote sleep, it may be continuously absent for 50 hours or 
longer. Somnolency, stupor, apathy, and coma come on in succession 
as the disease increases in severity ; at the same time the special senses 
become much blunted, as is well seen in the deafness which invariably 
accompanies the disease. General convulsions are rare, appearing occa- 
sionally towards the close of the disease ; and often indicating suppres- 
sion of urine. A fatal termination may be expected when such grave 
symptoms arise. 

Muscular System. — Prostration and a painful sense of weariness 
are among the premonitory symptoms ; and general muscular pains, 
simulating acute rheumatism and of considerable intensity, are sometimes 
present in the early stage. They are apt to mislead us in our diagnosis. 
Later in the disease paralysis affects the sphincters of the bladder and 
rectum, the evacuations are passed in bed, and the urine dribbles away 
from an over-distended bladder. The muscles of mastication, deglutition, 
and vocalization are similarly affected ; the tremulous tongue cannot be 
protruded, food or fluids are swallowed slowly and with difficulty, the voice 



TYPHUS FEVER. 291 

becomes feeble and the speech inarticulate. Muscular tremor is invariably 
present, and sometimes tonic spasm affects some group of muscles. 

Respirators System. — Pulmonary complications are very common, 
Bronchitis occurs to some extent in almost every case. Pneumonic and 
Hypostatic congestions are also very common, the former occurring in 
the earlier stages, the latter towards the crisis. They are indicated by 
urgent breathing, and lividity of the lips and face. Pain is rarely com- 
plained of, and the cough and expectoration are not in proportion to the 
pulmonary disease. Quick breathing, a little wheezing with a slight 
cough, and occasional expectoration of colourless, frothy, or russet and 
viscid sputum, are sufficient indications of pulmonary mischief, and, on 
examining the chest, we may detect pi etty general mucous rhonchus and 
crepitation. Crepitation is commonly to be heard at the back of the 
chest. Congestion is indicated by dulness and bronchophony. Pleurisy 
occasionally supervenes in a still more insidious manner, the effusion 
being fluid in most cases ; in others, acute pain and the usual physical 
sjmiptoms of the disease are present. 

Glandular System. — 1. Affections of the Liver. — Jaundice is a 
very rare complication. 2. Inflammations of the parotid, axillary \ and 
cervical glands, rapidly running on to suppuration, are amongst the 
most severe complications. These affections often appear about the time 
of convalescence, and either prevent or greatly retard it, for the adjacent 
integument becomes indurated, and the sloughy cellular tissue surround- 
ing the glands separates very slowly. Buboes in the arm-pits and groins, 
and carbuncles, are of rare occurrence. Phlegmasia dolens is also a 
rare sequel. 3. Affections of the Kidneys. — In typhus the quantity of 
urine is diminished, colour reddish-brown, specific gravity high ; the 
quantity of urea is considerably increased, and uric acid is also increased. 
The chlorides gradually diminish, and are at last reduced to a mere trace. 
Dr. Buchanan gave a patient 1^ ounces of chloride of sodium, but not a 
trace could be detected in the urine afterwards. Albumen is found in 
about half the cases ; it commonly appears after the seventh day of the 
disease. Occasionally, suppression of urine occurs, and the patient dies 
comatose, with or without convulsions. 

The Skin and Integument. — 1. Boils sometimes appear during 
convalescence. 2. Erysipelas is apt to occur when prevalent. 4. Gan- 
grene and sloughing of the integuments, preceded by erythema of the 
skin, are common occurrences in the advanced stage of the disease, in 
parts liable to pressure. Large bed-sores are often formed over the 
sacrum and trochanters. 

Stages. — 1 . Period of Incubation about ten days. 2. The stage 
of invasion, extending from the commencement of the illness, to the 
appearance of the rash, from four to seven days. 3 r The stage of nervous 
irritation, restlessness, wakefulness, and delirium, extends from the end 
of the last stage till somnolency comes on, a period of three or four days. 
4. The typhous stage. This is the last stage of many other diseases, as 
well as of typhus, and is commonly called the " typhoid" stage. We 



292 TYPHUS FEYEP. 

abandon this term because it designates a particular fever, and use the 
word typhous in its place. The typhous stage is characterised by dorsal 
decubitus — a rapid thready pulse; muttering delirium, stupor, or im- 
perfect coma; a dull fixed eye ; an open mouth displaying a hard, dry, 
and brown tongue, with sordid lips and teeth, and exhaling an offensive 
odour. The evacuations are passed involuntarily, and the hands are con- 
vulsed. 5. The convalescent stage. A month is usually sufficient to 
restore the patient to health ; falling of the hair is common, but there is 
no permanent derangement of the functions. 

Duration. — Convalescence mostly commences on the fourteenth day, 
but in mild cases about the end of the first week. It is occasionally post- 
poned to the twenty- first day. 

Prognosis. — Favourable, if the patient be young, well nourished, 
and of a non-excitable temperament, if the pulse maintain moderate 
bulk, and do not exceed 120, and there be no tendency to pulmonary 
complication. Unfavourable, if the patient be beyond sixty, and feeble, 
if the pulse be weak and intermittent, or if it much exceed 120, if the 
rash rapidly become petechial, if pulmonary complications appear early. 

Mortality. — Out of 4,787 admissions into the London Fever Hos- 
pital, 1000 = 20-89 per cent. = 1 in 4*78 died. Deducting those 
cases which were fatal 24 hours after admission, the mortality falls to 
19*56 per cent. It is greater in males than in females. 

Pathology. — The blood is very dark and fluid; and if we meet 
with coagula, they are soft and friable. If pneumonia have existed, 
firm yellowish clots are found in the right side of the heart. Taken 
during life the blood is found to be deficient in fibrine; urea may often 
be detected in the serum, and ammonia is present in appreciable quan- 
tity. The Bile is dark and thick, like treacle. I have observed its 
specific gravity as high as 1050. With water, it forms a golden-yellow 
feebly alkaline solution, which possesses the reactions of healthy bile. 
On evaporation it yields a large quantity of glistening and brittle black 
residue, smelling strongly of fatty matter. Ihe Muscles, including 
the heart, are dark and easily lacerated. The Brain and nerve tissue 
are firm and healthy, but the cerebral membranes are commonly gorged 
with blood. Passive effusion of serum tainted with urea between the 
membranes and into the ventricles is one of the usual results of typhus ; 
inflammatory exsudations, such as jelly-like serum beneath the arach- 
noid, a few small patches of coagulated fibrine on the upper surface of 
the pia mater, and shreds of coagulated lymph in the lateral ventricles, 
are rare. The kidneys are often found greatly congested. The alimen- 
tary canal is everywhere healthy, or only congested in its most vascular 
portions. The liver and spleen are more or le>s congested and softened. 
Effusions into the serous cavities are common. The respiratory organs 
show various lesions. The mucous membrane of the respiratory tract 
is injected and soil ; the lungs may be cedematous, engorged, or partly 
consolidated. The air-tubes are commonly filled with frothy fluid. 



TYPHUS FEYEE. 293 

Geographical Distribution. — Typhus is common to every coun- 
try of Europe, and is therefore so far indepeudent of climate. Italy, 
Spain, and Great Britain appear to have suffered most from its ravages ; 
and Ireland has been so little free from it that it would appear to be 
endemic there. It is prevalent in Canada and the United States. We 
have no evidence of its existing in Australia and Xew Zealand. Of its 
existence in South America, in Asia, and in Africa, we want positive 
proof, fevers of all kinds having been much confused in these parts of 
the globe. Many have thought that the plague is the typhus of tropical 
countries. 

Causes. — 1 . Predisposing : Depression of the vital power from men- 
tal or bodily exhaustion ; hence the disease most commonly attacks those 
of adult age. Season and Temperature : Typhus appears to prevail, 
caeteris paribus, irrespective of these conditions. Overcrowding with 
imperfect ventilation and insufficiency of food are both veiy powerful 
predisposing causes. Even in London, typhus is rare among the middle 
and upper classes. The severest epidemics have appeared in times of 
scarcity. 

2. Exciting : The infection of a specific poison generated within the 
bodies of persons suffering from prolonged want of sufficient food, and 
exposed to animal exhalations. Mo other fever is so infectious as typhus. 
It spreads quickly through a family : nurses and medical attendants, if 
they do not use sufficient precaution, invariably take it. The poison is 
contained in the cutaneous and pulmonary exhalations of the patient, 
and is no doubt introduced into the system of other persons through 
the lungs. 

Diagnosis. — Extreme muscular prostration,with general dull aching 
pains, a weak pulse, dusky complexion, dulness of the senses and intel- 
lect, heavy persistent headache, a peculiar dusky eruption, and a bad 
odour of the body, are the marks of typhus. Excepting the rash, how- 
ever, which does not appear until the fourth or fifth day, these are not 
very conclusive symptoms ; and there may be much doubt as to the 
true nature of the disease during its early stages, when it may be con- 
fused with enteric and relapsing fevers, measles, phrenitis, suppression 
of urine, and with such diseases as pneumonia and pyaemia, when they 
assume the typhous condition. 

Enteric and relapsing fevers are distinguished at pp. 300, 305. 
Rubeola, coryza, and catarrh distinguish this disease, and the rash is 
peculiarly patchy, and of a much brighter colour than in typhus. 
Phrenitis is ushered in by great irritability of temper ; the senses are 
painfully acute, so that light and sound are intolerable, and the eyes are 
bright and wild. Strabismus is a common symptom : there is often 
sympathetic vomiting; there is no rash. If meningitis be present, we 
have superadded to the symptoms of phrenitis those of acute mauia, with 
intolerable pain in the head. 

Low forms of inflammation of the brain are distinguished with great 
difficulty. The history of the case, and the absence of much fever and 



294 TYPHUS FEVER. 

rash, will serve to guide us. Uraemia is characterised by the sudden 
accession of stupor, rapidly passing into coma. Convulsions, which are 
rare in typhus, are generally present in this disease. Pneumonia. — 
General pneumonic engorgement of asthenic form is still more difficult 
to distinguish from typhus ; indeed, the typhus poison, in common with 
other animal poisons, often produces rapid engorgement of the lungs and 
depression of the vital power, and death occurs in such cases before 
specific symptoms of the fever have had time to declare themselves. 

Prophylaxis and Disinfection. — Avoid the exhalations from the 
patient ; dilute and carry them away by direct and free ventilation ; dis- 
tribute about the room lumps of wood charcoal ; expose all articles of 
clothing infected with the disease to the action of boiling water, or to 
steam, and subsequently rinse them in water holding carbolic acid in 
solution. Mattresses should be well baked in an oven, and the feathers 
of feather-beds should be submitted to a process of purification. 

Treatment. — The patient should be placed in a cool, well-ventilated 
room, in which a brisk fire is constantly burning, with a nurse in con- 
stant attendance. If the skin be pungently hot, the patient should be 
immersed for five minutes in a hot bath ; if there is less heat of skin, 
tepid sponging will suffice. 

The heat of the head may be allayed by iced water, poured in a small 
continuous stream from a height for the space of ten or fifteen minutes. 
The head should be shaved whenever the brain symptoms are severe, and 
if the headache be not relieved by the cold douche, blisters should be 
freely applied to the forehead, or to the whole of the scalp. The bowels 
should be kept in free action by the help of cho'agogue purgatives. 
Sleeplessness, nervous excitement, and delirium must be combated by 
hypnotics. Opium is the remedy: it should be given in moderate doses 
at first, such as fifteen drops of tincture, or five grains of compound soap 
pill ; but if this fail to fulfil the object the dose may be doubled or trebled. 

But the indication for treatment of all others is to support the failing 
strength. The constant attention of good nursing is indispensable ; the 
means are diet and medicine. In the early stages food is generally taken 
well, but the digestive organs are not in a state to dissolve solid food. 
The diet should consist of eggs, milk, beef-tea ; three or four eggs may 
be given daily : they should be given with tea or coffee in the ibrm of 
emulsion. Alcoholic stimulants are invaluable in typhus, and may be 
administered throughout the disease. In their exhibition we must be 
guided by the state of the pulse. If the pulse be of fair volume and 
under 110, little or no alcohol will be needed. If it be failing, and the 
patient cannot take much food, we may give from Jvj. to Jxyj. of brandy 
or an equivalent quantity of wine in the twenty-four hours. Brandy is 
the best kind of stimulant ; it may be given quite irrespective of delirium ; 
it should be mixed with water or milk, and given eveiy one or two hours. 

Of medicinal stimulants ammonia is the best. (See Forms. 1, 6.) 

Quinine and acid is not always well assimilated during the height of 
the fever, but after the crisis it is a very useful combination. 

Strict attention must be paid to the state of the bladder, especially in 






CEKEBEO-SPDsAL FEYEE. 295 

the later stages of the disease, when the patient becomes apathetic and 
the muscular tissues fail in contractile power. If the urine accumulate 
in the bladder, it must be drawn off twice a day. If the quantity be 
much diminished we must resort to brisk hydragogue purgatives, and 
apply mustard poultices to the loins. 

We must carefully examine, irom day to day, the state of the integu- 
ments over the sacrum and trochanters : and as often ascertain the tem- 
perature of the feet. Bedsores and mortification of the toes are grave 
complications which, in nineteen cases out of twenty, may be prevented 
by proper vigilance on the part of the medical attendant. 

The breathing must be carefully noticed. If the inspirations exceed 
twenty-five per minute, we must examine the chest. If pleuritis or 
pneumonia be present, blisters will be necessary. If there be cough and 
wheezing, with hurried breathing and mucous crepitation in the lungs, 
mustard poultices and turpentine stupes may be advantageously applied 
to the chest, and expectorant stimulants (Form. 235) administered. 

If inflammatory swelling of the parotid arise, we must endeavour to 
prevent suppuration by the usual means. Hall'-a-dozen leeches may be 
applied. As this is a complication which supervenes about the time of 
convalescence, we may generally exhibit iron and quinine freely. The 
quantity of alcoholic stimulant should at the same time be increased, 
and the diet should be as full and nutritious as possible. As soon as fluc- 
tuation is detected, the pus should be let out by free incision. 



CEREBROSPINAL FEVER. 



Under the terms, Epidemic Cerebro-spinal Meningitis, Purpuric Fever, 
&c., a variety of typhus in which spinal symptoms are prominent has 
been described. The early symptoms are those of typhus, with more 
severe myalgia than usual. Pain in the muscles of the neck is espe- 
cially complained of; and the body generally, but more especially the 
spine and abdomen, is affected with acute neuralgic pains. The delirium 
and stupor are always great ; the head is stiffly retracted and the 
muscles generally are in a state of tetanoid rigidity or spasm. As the 
patient lies a little over to one side, the body is often stiffly arched back- 
wards ; sometimes an arm is constantly retracted ; sometimes the legs 
are rigidly flexed upon the thighs ; occasionally the muscles of the face 
and eyeballs are implicated, as indicated by trismus, fixed risus, or 
strabismus. In the larger number of cases, a cutaneous petechial rash 
appears very early, and the petechia? often enlarge to form large blackish 
blotches, which may become raised, vesicular, and sometimes gangrenous. 
In some outbreaks herpetic eruptions are common. 

At first there is hyperesthesia, but the patient soon lapses into a 
comatose state, and usually dies between the first and the eighth days. 
The progress of the disease is sometimes so rapid that the usual pre- 
monitory symptoms are absent, and the patient falls into a state of 
collapse, rapidly passing into coma, purpuric blotches appearing simul- 
taneously. 



296 ENTERIC FEVER. 

After death, great vascularity of the pia mater of the brain and spinal 
cord, with more or less clear or milky serum effused into its meshes, will 
be discovered. 

Examples of this variety of fever occur every now and then during 
the progress of typhus. Epidemics have" been particularly noticed in 
the United States, on the banks of the lower Vistula, and in Ireland. 
The treatment is that of ordinary typhus, with especial regard to the 
cerebro-spinal symptoms. The shaved scalp should be blistered, and a 
long narrow strip of blistering plaster placed over the upper half of 
the spine. 



ENTERIC FEVER. 

Synonyms. — Typhoid, pythogenic, gastric, intestinal, bilious con- 
tinued, and cesspool fevers ; muco-enteritis. 

Definition. — An endemic contagious fever, generated by the inges- 
tion of decomposing animal matter. 

Symptoms. — The onset of the disease is generally very insidious. 
There are no marked premonitory symptoms : chilliness, loss of appe- 
tite, and slight pyrexia — sometimes accompanied by nausea and a little 
diarrhoea, and sometimes not — mark the outset of the disease in most cases. 
In others, vomiting and diarrhoea, with some abdominal tenderness, are 
the earliest indications. On careful examination some evidence of gastro- 
intestinal irritation will always be found. The tongue is furred and red 
at the tip and edges ; the pulse is small, frequent, and sharp ; the face is 
pale and somewhat pinched ; but the cheeks have a circumscribed blush. 
Tenderness will generally be complained of on pressing the abdomen. 
The patient becomes weak, the skin is hot and dry, the lips cracked. 
There is complete anorexia and much thirst. In this condition the 
patient generally comes, for the first time, under the notice of the medical 
practitioner, and states that he has been feeling unwell for about a week. 
On the seventh day, or a little later, a few round, well-defined rose- 
coloured spots make their appearance on the abdomen, chest, and back 
of the patient. These spots somewhat resemble the papulae of variola 
during the first few hours of their existence, but they are not so large 
or so hard. They are elevated and prominent, and disappear on pressure. 
In at least one half of the cases, and in the worst form of the disease, 
they are altogether absent. When present, the number varies consider- 
ably : in most cases they are very few, and may easily be overlooked. 
At this stage of the disease we shall rarely observe more than half a 
dozen over the whole of the chest and abdomen, and very often not more 
than three. The quantity of the rash bears no proportion to the severity 
of the disease. Forty-eight hours after their appearance the spots begin 
to fade and new ones arise, which in like manner disappear, and are 
succeeded by another crop. The abdomen now will usually be found 
more or less tympanitic and tender, the tenderest part being the right 
iliac fossa, where pressure commonly produces gurgling. If the bowels 



ENTERIC FEVER. 297 

have not yet been relaxed, diarrhoea usually sets in now with greater or 
less severity. The stools are watery, and of a light yellow colour ; the 
tongue is covered with dirty-white fur, and is cracked and aphthous. It 
the purging continue, it becomes dry, brown, and contracted, or red and 
glazed ; it is usually more or less fissured, and it is often covered with 
large patches of superficial ulceration. The teeth are crusted with 
sordes; the pulse ranges between 90 and 120; the skin and head are 
hot, and there may be much delirium ; the cheeks wear a hectic blush. 
During the secoad week of the disease, and afterwards, haemorrhage 
from the bowels may occur. The patient may become suddenly blanched 
and die without the discharge of blood per anum, and in such a case the 
intestines will be found distended with blood. In other cases the haemor- 
rhage recurs at intervals, and the patient becomes pallid and much 
prostrated. Haemorrhage, however, is not the only danger we have to 
anticipate. The patient is often cut off by perforation of the intestine. 
This dreaded result may be expected if the purging be frequent and per- 
sistent, if the tenderness and tympanites increase, and if vomiting and 
hiccough supervene. Perforation is most commonly preceded by symp- 
toms of general peritonitis, accompanied by excessive tympanites and 
persistent hiccough and vomiting. A paroxysm of more intense abdomi- 
nal pain may indicate that perforation has taken place, or previous to 
such a complication the patient may sink and die. 

The patient may be conscious and acutely sensible of his condition 
throughout the disease to within an hour or two of his death ; but when 
the diarrhoea is very exhausting and protracted he usually falls into a 
state of apathy, with a little delirium at night. He lies motionless in 
bed, and is now liable to bedsores. Emaciation occurs very rapidly, and 
if no amendment takes place the typhous condition becomes established : 
the tongue and teeth are blackened with sordes ; stupor, with convulsive 
twitchings, delirium, and coma, succeed each other ; the watery motions 
are passed involuntarily, and the patient gradually sinks. 

In favourable cases the improvement is generally very slow. The 
number of stools gradually diminishes, and they become more and more 
solid ; no fresh spots appear ; the temperature of the skin falls, and per- 
spiration appears ; the tongue begins to clean, and the appetite quickly 
returns. 

Such are the usual symptoms ; but they are subject to considerable 
variation. Profuse diarrhoea, with vomiting, may be amongst the earliest 
symptoms. In some cases the bowels are constipated throughout. In 
the very mildest cases the worst complications may at any time supervene. 
There may be noisy delirium from the commencement of the disease. 

Convalescence is in some cases interrupted by a relapse, generally trace- 
able to some error of diet ; a crop of fresh spots appear, and diarrhoea 
again sets in, to be followed perhaps by more urgent symptoms. 

The average duration is above four weeks : it is rarely terminated in 
three weeks. If the attack have been severe, convalescence will be very 
much protracted, and the patient will not be safe for many weeks. 

Complications and Seqtjel/E. — Diseases of the respiratory organs 



298 ENTERIC FEVEB. 

— bronchitis, pleurisy, and pneumonia — are frequent complications of 
enteric fever. Laryngitis, with croupous exsudations, and ulceration, is 
not uncommon. Impending suffocation is sometimes relieved by the 
ejection of fragments of a tough membrane. In such a case aphonia 
may result, and continue for several weeks. Abortion and phlegmasia 
dolens are liable to occur during an attack of enteric fever. Peritonitis, 
perforation, and haemorrhage occur as natural results of the progress of 
the disease. If the ulcers of the intestine erode a small artery, more or 
less haemorrhage occurs. If the progress of the ulceration be not checked, 
the ulcers extend through the mucous, areolar, and muscular coats, and 
reach the peritoneal covering, and excite inflammation, which rapidly 
spreads and becomes general. Perforation is rarer than is generally 
supposed. The deepest part of the ulcer often, indeed, lies on the at- 
tenuated peritoneum, which here and there presents a slough, pretty 
firmly adherent, and retained in its position by solid effusion on the 
intensely-inflamed serous surface. When perforation occurs, the peri- 
toneal coat becomes excessively thin, and gives way in one or more places. 
The apertures are generally small and rounded. Inflammation and 
suppuration of the pjarotid sometimes occurs, but more rarely than in 
typhus. Marasmus is almost a necessary result of a severe form of the 
disease, since the mesenteric glands, as well as the solitary and agminated 
glands of the intestine, are so directly and extensively involved. 

Pathology. — Whatever be the ultimate cause of enteric fever it 
essentially manifests itself in derangement of function, and in lesion of 
structure of the alimentary canal. The lips are cracked ; the tongue 
fissured, and often covered with ragged aphthous ulcers ; and the pharynx 
and oesophagus occasionally present the same lesions if the disease be pro- 
tracted beyond the third week. The stomach and duodenum, however, 
are unaffected, and the disease chiefly, in many cases exclusively, attacks 
the lower part of the small and the large intestines. But it is upon the 
solitary and agminate! glands (Peyer's patches; of the lovser third of the 
ileum that the disease expends its virulence. There we invariably find 
disease after death from enteric fever. In the early stage of the disease 
(on the fifth or sixth day) these normally obscure glands are swollen 
and distinctly elevated above the surrounding mucous membrane ; at the 
same time they become vascular ; the blood-vessels of the surrounding 
mucous membrane are seen converging towards their centies; and the 
coiTes}x>nding part of the peritoneum presents a patch of dilated vessels. 
The enlargement and vascularity increase, and the swollen gland becomes 
soft and abraded ; and this first stage of degeneration is quickly suc- 
ceeded by sloughing or ulceration. Sometimes a whole Peyer's patch is 
covered wuth a discoloured, ashy-looking slough. When the slough has 
separated, or the ulcer advanced, the surface exhibits a rugged appear- 
ance, being formed of angry-looking granulations, of various sizes, enclosed 
in an irregular network of sloughy areolar tissue. The edges of the ulcer 
are hard and elevated ; externally they are rounded and smooth, inter- 
nally they are ragged with excavations. In proportion as the base of 
the ulcer nears the peritoneum, so does that membrane increase in in- 



ENTERIC FEYER. 299 

flammation ; and if the ulcers be numerous the inflamed patches become 
confluent, and the outer surface presents the appearance of intense inflam- 
mation, and may be covered with plastic lymph. As soon as ulceration 
extends to this covering, perforation impends. The event, however, is 
often retarded for a time by the adhesion of the part to a contiguous coil 
of intestine; or by the deposition of solid lymph upon its outer surface. 
The aperture formed in the peritoneum rarely exceeds three lines. 

The ulcers are in proportion to the number of the glands, or size of 
the patch affected: if a single gland, or only two or three, the ulcer is 
a small spot ; if a Peyer's patch, then there will be a rounded or oval 
ulcer, varying in size from a quarter of an inch to an inch and a half. 
The ulcers are sometimes confluent. 

On recovery from the attack the ulcers heal, cicatrize, contract, and 
ultimately form a smooth, depressed surface, thinner and less vascular 
than the suiTounding healthy coat. 

When the large intestine is implicated, the disease is usually confined 
to the caecum and the ascending colon. The csecum is often severely 
affected. The ulcers in this part of the alimentary canal are small, 
round, and uniform in size, unless they become confluent. 

The mesenteric glands show their sympathy, if not their identity in ana- 
tomical structure and function, with the solitary and agminatecl glands, 
in becoming inflamed and swollen to several times their natural size. The 
inflammation may go on to suppuration. 

The spleen is enlarged and softened and congested. 

The liver speedily becomes fatty and enlarged. The mucous membrane 
of the gall-bladder is frequently found inflamed, but rarely ulcerated. 

The bile is thin and almost colourless, commonly acid, and of low 
specific gravity, and yields a very small proportion of solid matter. 

Geographical Distribution. — Enteric fever prevails generally 
over all the world. 

Causes. — 1. Predisposing. Youth. — The mean age of 1772 cases 
admitted into the London Fever Hospital during ten years was 21. Of 
these half were between 15 and 25, one-fifth were under 15, less than 
one-seventh were above 30, and less than one-sixtieth exceeded 50. 

Season. — Enteric fever is an autumnal disease; though it mav and 
does prevail during winter, spring, and summer, it is more prevalent 
in dry and hot than in cold and wet seasons. 

2. Exciting. — Exhalations from putrid decay of animal matter. The 
following instances which are advanced to establish this point are cited 
..in Dr. Alurchison's work on the Continued Fevers of Great Britain. 
I. Twenty out of twenty -two boys, at a certain school, were seized with 
fever, accompanied by symptoms of severe gastro-intestinal irritation. 
Two of the fatal cases were examined, and the usual lesions of Peyer's 
patches, and the solitary and mesenteric glands, were discovered. 'The 
cause was attributed to the opening, two days before the first case of ill- 



300 ENTERIC FEVEE. 

ness, of a drain at the back of the house, which had been choked up for 
many years, and the distribution of its offensive contents over a garden 
adjoining the boys' playground. 

II. In the year 1838 an epidemic of enteric fever desolated a commune 
in the department of Ariege. Nearly half the inhabitants were attacked, 
and nearly a third of these died. The cause of the epidemic was traced 
to a stagnant pool, the receptacle of dead animals and of all the sewage 
of the district. Three times the pestilence returned, and each time when 
the wind was blowing over the infected water. 

In these cases it is assumed that the poison was conveyed by the air. 
In the following case it appears to have been introduced into the system 
by water : — 

III. The inhabitants of thirteen out of thirty-four houses of a certain 
crescent derived their drinking water from a well at one end of it ; the 
remainder were supplied with water from another source. At the end 
of September it was evident that the water from the pump was tainted 
with sewage. Early in October intestinal fever broke out almost simul- 
taneously in all the thirteen houses using the water. 

Some observers, however, attribute the disease to a specific poison, 
contained in the alvine excretions of persons suffering from the disease, 
and deny that it may be spontaneously generated by putrid animal mat- 
ter. Observed facts and the few experiments which have been made 
tend, however, to disprove these views. 

Contagion and Infection. — Much doubt prevails whether entei ic fever 
be infectious or not ; and the question really turns upon the existence of 
a distinct specific poison. Positive proof that it may be conveyed from 
one person to another is wanting, and certainly the majority of people 
affected with the disease derive it, upon the clearest evidence, directly 
from one and the same source. Those in attendance upon persons suf- 
fering from enteric fever do sometimes fall ill of the disease, but the 
source of the disease may be present in any house. 

Diagnosis. — In the early stage, enteric fever may be mistaken for 
typhus, relapsing fever, and variola. The difference between typhus 
and enteric fever have reference — 1. To the general phenomena of the 
two diseases. Great muscular prostration and early cei ebral disturbance, 
with dulness of the senses and mental faculties, mark the onset of 
typhus ; while symptoms, more or less obscure, of gastro -intestinal dis- 
turbance indicate the presence of enteric fever ; but sickness and diarrhoea 
may be absent in enteric fever, and head symptoms may be prominent 
from the first in this disease. 2. Abdominal tenderness about the 
umbilicus and right iliac fossa, and, 3. A moist thickly-furred aphthous 
tongue, may inform us that the disease is enteric, and not typhus fever. 

4. Light ochre-coloured fluid stools are diagnostic of enteric fever. 

5. When the eruption appears the diagnosis becomes certain. In typhus 
the rash appears about the fourth day; in enteric not before the seventh. 
In typhus it consists of a diffused dusky mottling composed of irregular, 
uncircum scribed non- or barely elevated spots, tending to fade into dirty 
discoloration, or to become distinct petechias. In enteric fever the rash 



ENTERIC FEVER. 301 

appears much later, never gives a mottle 1 appearance to the skin, and is 
never confluent. The constituent spots are rose-coloured, circumscribed, 
isolated, and elevated, so as to be distinctly felt by the finger ; they 
always disappear on pressure and never become petechial. The only 
difficulty in diagnosis by the skin is that the freckled or mottled skin 
often seen in dark complexions, or when certain faint syphilitic maculae 
are present, may so mislead us that we may fail to observe the three or 
four minute pink papulae which indicate the presence of enteric fever. 
6. The progress and duration of the disease. — The dusky blush suffus- 
ing the head and neck in typhus, contrasts with the ciicumscribed hectic 
flush and pinched features of enteric fever. The one disease tends to 
death by coma, the other to death by asthenia ; typhus kills or shows 
signs of departure in the second week, enteric fever continues for three 
or four weeks. 

Variola. — If the lumbar pain be absent in the accession of this disease, 
and the eruption make its first appearance as a few isolated papules upon 
the chest and abdomen, the case may be doubtful for a day. For ex- 
ample, a patient has been feeling poorly for a week before he is seen, 
and then he is in a state of high fever, complaining of headache and 
great and persistent nausea, but there is no vomiting nor lumbar pain ; 
he presents a large but faint vaccine scar ; the tongue is coated with 
a dirty-white fur, the abdomen painful on pressure, and there is a 
distinct gurgling in the right iliac fossa, resulting, no doubt, from free 
action of the bowels induced by a purgative previously administered. 
Next day the tongue is dry and brown, and seven elevated rose-coloured 
papulae, completely resembling those of enteric fever, are scattered over 
the abdomen and chest. There is no trace of eruption, or of that rough- 
ness of the skin which precedes it, on the face or any other part of the 
body. In this stage it will be impossible to decide whether the case is 
one of small-pox or enteric fever, and we must defer our diagnosis for 
a while. A few hours, however, will be sufficient to decide the matter. 
In the case alluded to, after a copious sweat the papules became harder 
and more prominent, and others began to appear on the face and limbs, 
and the case proved to be one of discrete variola. 

Chronic Tubercular Peritonitis presents many of the symptoms of 
enteric fever. The hectic flush, pinched features, abdominal pain, ten- 
derness and gurgling, anorexia and diarrhoea, are all present in this 
disease, but the tongue is usually moist and clean, there is no eruption, 
and frequently the abdomen is distended with effusion ; moreover, there 
may be evidence of tubercular deposit in the lungs. 

Prophylaxis and Disinfection. — "Whenever a case of enteric fever 
occurs in a given locality, we must examine into the condition of the 
drains and the nature of the drinking water, and ascertain whether there 
be an offensive accumulation of decomposing animal matter near the 
house. If it can be done speedily and without temporarily increasing 
the nuisance, drains should be cleared and flushed, and offensive accu- 
mulations removed. In the absence of all other water, that which is 



302 ENTERIC FEVER. 

contaminated must be filtered through charcoal and boiled before it is 
used ; but whenever it is practicable the patient should be removed to 
a healthy locality. The dejections of patients suffering from tiie disease 
should be mixed with solutions of chloride of zinc or lime, or with a small 
quantity of hydrochloric acid, and be speedily removed. Bad odours 
should be traced at once to their source and the cause removed, or their 
diffusion prevented by the substitution of stench-traps for open grating. 
A sufficient fall for the sewage should be provided, and in seasons of 
drought the drains should be occasionally flushed. Pipes connecting the 
waterclosets with the drain or sewer should be constructed of iron, and 
always placed on the outside of the wall of the house. If made of lead 
(which is readily eroded by rats) and carried down the inside of the 
house, the apartments are liable to be filled with foul air derived directly 
from the sewer. 

When it is necessary to open a drain, or to empty cesspools, disinfec- 
tants should be freely used, and the air thoroughly impregnated with 
free chlorine. Fresh mould, lime, soot, and solution of chloride of zinc 
should be mixed occasionally with the offensive matter. The chlorine 
may be evolved from a mixture composed of Jiv each of finely powdered 
Hack oxide of manganese and common salt, and Jviii of sulphuric acid 
diluted with a little water, placed in a deep dish. 

Treatment. — In the present state of our knowledge enteric fever 
must be treated as a purely local disease. We presume ulceration of the 
intestines, and we fear its worst results. We know of no means of pre- 
venting the deposition of morbid material in the glandula? of the intes- 
tinal canal, and when the patient comes under our notice it is generally 
too late to adopt an eliminative plan of treatment with the view of pre- 
venting further deposit and of removing that aheady formed. If, how- 
ever, we see the case sufficiently early and have grounds enough to form 
a diagnosis, we may hope to arrest its further progress by judicious 
treatment. We shall often find that the alvine secretions are retained, 
and in many cases the secretions defective. The bowels should be care- 
fully relieved by means of castor oil and enemata, and then we may ad- 
minister small and repeated doses of grey powder until the constitutional 
effects of mercury, slight redness and tumidity, with tenderness of the 
margin of the gums, appear. 

The diet must be carefully regulated : all solid food must be avoided ; 
eggs, milk, and arrowroot in various combinations should form the staple 
articles of food. The eggs should be lightly boiled, or given in emulsion 
with coffee or tea. Beef-tea may be frequently given ; a few ounces of 
red wine may be allowed from the first, and increased to a pint or more 
during the progress of the disease if the strength fails. 

If at any time in the course of the disease the bowels be constipated, 
iss of castor oil in combination with 10 drops of tincture of opium may 
be given. Sickness is best combated by iced soda-water to which a few 
drops of hvdrocyanic acid have been added. If there be much abdominal 
tenderness half a dozen leeches may be applied to the right iliac region, 
or around tne margin of the anus. If the pain and tenderness be slight, 



RELAPSFNG OR FAMINE FEVER. 303 

hot fomentations, mustard poultices, or turpentine stupes, applied to the 
abdomen, may be sufficient. The diarrhoea must be kept within the limits 
of one or two loose stools a day, and for this purpose we may employ 
the medicines prescribed in Forms. 166, 175. Moderate doses of opium 
alone are sometimes sufficient. If it continue unrestrained by these re- 
medies we must use in addition an enema once or twice a day, composed 
of ^iij of starch water aud xv drops of tincture of opium. If haemor- 
rhage occur, we must increase the dose of the astringent, or we may 
substitute for the lead and copper salts, five-grain doses of gallic acid ; 
cold fluids should be given, and a bladder of ice placed over the right 
iliac fossa. Turpentine in x or xx minim doses is a valuable remedy in 
haemorrhage, and it is also useful in relieving the tympanites that often 
accompanies it. Assafoetida enemata are also useful in tympanites, 
which is sometimes very great, and while it causes severe pain, it at the 
same time places the life of the patient in great jeopardy, laceration of 
the diseased and attenuated coat of the intestine being very imminent 
in this distended condition. 

If peritonitis, with or without perforation, supervene, we must ex- 
hibit opium very freely ; i or ii grains of the powder may be given every 
two or three hours ; hot fomentations, or a large blister, may be applied 
to the abdomen. Hiccough is often a most painful complication, but 
may be readily relieved by the inhalation of chloroform. 

In the absence of very severe symptoms, small doses (J grain) of qui- 
nine in combination with xv drops of dilute sulphuric acid, and an ounce 
of decoction of cinchona, may be given twice or thrice a day throughout 
the disease. 

Head symptoms and pulmonary complications require such treatment 
as is recommended in typhus fever. 

During convalescence we must patiently pursue the same plan of 
treatment as regards diet and tonic astringent medicines. As the appe- 
tite improves and the stools become less frequent, darker and more solid, 
we may increase the quantity of food, and substitute another egg and a 
little fish in place of beef-tea, but on no account must solid meat or vege- 
tables be taken for a full fortnight after the stools have become solid. 
An egg boiled moderately hard will sometimes be sufficient to produce 
a recurrence of diarrhoea and bring on a relapse. Cod liver oil is useful, 
when the stomach bears it, in removing emaciation. 



RELAPSING or FAMINE FEVER. 

Synonyms. — Five or seven days' fever. Epidemic remittent fever. 
Bilious relapsing fever. Famine fever. 

Definition. — A contagious fever, of from three to seven days' dura- 
tion, abruptly terminating, and recurring after complete apyretic inter- 
vals of about a week. 

Symptoms. — Sudden and severe rigors, coming on without premoni- 



304 RELAPSING OR FAMINE FEVER. 

toiy symptoms, and when the person is engaged in his ordinary occu- 
pations ; severe headache and muscular pains speedily follow. After an 
hour or two, intense febrile symptoms appear, with a full, bounding 
pulse ; a dry, burning skin ; the tongue is coated with a white fur ; 
there is severe pain in the epigastrium and vomiting of bilious fluid or 
of black, coffee-ground matters. The bowels are constipated and the 
urine scanty and high-coloured. On the third, fourth, or fifth day 
jaundice occurs in 20 per cent, of the cases. The stools are dark or 
even black, and melaena is sometimes noticed. The headache assumes a 
throbbing character ; the intellect remains quite clear ; but there is 
constant watchfulness and great restlessness. 

At the end of five or six days, sometimes earlier, sometimes later, 
the patient breaks out into a profuse perspiration, often accompanied by 
diarrhoea, and sometimes by intestinal or uterine haemorrhage : the 
febrile symptoms are thus brought to an abrupt termination, and the 
patient feels peifectly well, eats, drinks, and goes about as usual. After 
a week, or more rarely a fortnight, he suddenly relapses into his former 
febrile condition. This second attack may be less or more severe than 
the first : in the latter case severe jaundice and delirium may be pre- 
sent. After usually three days, a second intermission occurs, and the 
patient is restored again for a time to comparative health, complaining 
only of slight languor. A second or third relapse, at intervals of a 
week, may occur ; but in some cases the patient recovers without a 
single relapse. Occasionally sudden collapse takes place, the patient 
becomes cold, livid, and comatose, and dies a few hours after the acces- 
sion of the disease. 

Complications and Consequences. — A critical diarrhoea, in some 
cases slight, and readily controlled ; in others restrained with difficulty, 
and attended with considerable griping and tenesmus. Occasionally 
severe dysenteric symptoms persist, and cause death. Chronic in- 
flammation of the mucous membrane of the pharynx and trachea is 
of occasional occurrence. Menorrhagia and abortion are frequent 
complications in women. 

Mortality. — Relapsing fever is not very fatal. Of 441 cases ad- 
mitted into the London Fever Hospital, only ll = 2Jper cent, were 
fatal. The mortality, however, is greater in some epidemics than in 
others. In the Scotch epidemic of 1843, it was as high as 4 per cent. 

Prognosis. — Favourable, if the patient be young and vigorous, and 
in the absence of complications. Less favourable, after middle age, if 
much jaundice be present, and persistent diarrhoea supervene. Unfa- 
vourable, if there be suppression of urine. 

Pathology. — No specific lesions of structure are found in this 
disease. The tissues are usually more or less jaundiced. If gastro- 
intestinal symptoms have been present, patches of ecchymosed mucou/ 
membrane may be found in any part of the alimentary canal. TW 
lower part of the ileum in particular is usually greatly congested ; bu 
neither Peyer's patches nor the mesenteric glands are in any way disease' 



RELAPSING OR FAMINE FEVER. 305 

The liver is congested, the gall- bladder and ducts are healthy ; but the 
bile is dark and very thick. The spleen is greatly enlarged, engorged, 
and soft. The blood is said to contain an unusual number of white cor- 
puscles. The kidneys are commonly congested. 

Geographical Distribution. — Relapsing fever, like typhus, ap- 
pears to be more prevalent in Britain and Ireland than elsewhere. 
Ireland is its favourite habitat, and it has oftener prevailed in Scotland 
than in England. It has been observed among the inhabitants of Silesia, 
and in 1855 attacked our troops in the Crimea. It has been observed 
in several parts of North America. It is unknown in tropical countries. 

Causes. — 1. Predisposing. Eecent residence in London. " Of 380 
cases admitted into the London Fever Hospital, in which the circum- 
stance was noted, one-eleventh had not resided in London more than 
three months, and many only a few days ; more than one-seventh had 
not resided more than six months ; and considerably upwards of one- 
fourth not more than a year." — Murchison. 

Overcrowding and destitution favour the propagation of relapsing 
fever. The patients admitted into the London Fever Hospital come 
from the poorest and most populous districts, and the severest epidemics 
have occurred in times of famine. 

2. Exciting. A specific poison generated in the bodies of persons in 
a state of starvation, and readily communicated to others. Medical 
men who have had experience of the disease are almost unanimous in 
the opinion that it is infectious. It successively attacks the members 
of a family, and spreads through contiguous houses. There are fair 
grounds for assuming that the disease has been several times imported 
both into England and Scotland from Ireland. The Scotch epidemic of 
1847 has been ascribed to the immigration of a large number of desti- 
tute Irish ; and the epidemics in New York and other North American 
towns have been referred to the same cause. Medical men and nurses 
are liable to take the disease from patients. 

Diagnosis. — Relapsing fever is liable to be mistaken for the other 
infectious fevers, and also for remittent fever. From typhus and enteric 
fevers it is distinguished — 1. By its sudden invasion, without any warn- 
ing. 2. By the absence of rash. 3. By the complete intermission and 
relapse. In typhus fever cerebral symptoms are prominent. It is only 
in those rare cases of relapsing fever in which collapse and coma come 
on, that we can confound the two diseases. Enteric fever comes on im- 
perceptibly, and the febrile symptoms are but slight in the earlier part 
of this disease. Moreover, vomiting, jaundice, and enlargement of the 
liver and spleen are often present in relapsing fever. 

Relapsing fever is much more likely to be mistaken for Remittent 
fever, but the latter disease occurs in a malarious district, and it is non- 
infectious. Drs. Graves and Stokes, of Dublin, have called relapsing 
fever the " yellow fever of the British Islands." There are, indeed, so 
many points of resemblance between them, that the yellow fever of the 

x 



306 RELAPSFNG OR FAMINE FEVER. 

tropics would appear at first sight to be little more than a severe form 
of relapsing fever. But as far as our knowledge extends, the diseases 
differ in their origin, their predilection, and modes of propagation, and 
we are therefore bound to regard them as distinct maladies. 

Lastly, the access of relapsing fever may be confounded with that of 
Variola. Lumbar pain, vomiting, and high fever attend the onset of 
both diseases ; and, unless jaundice make its appearance, we may for 
the first day be uncertain whether the case is one of relapsing fever. 

Treatment should be directed to the relief of the congestion of 
the internal organ. Vomiting may be encouraged for a time ; or, if 
it be absent, it may be induced (Form. 220). Cholagogue purgatives 
(Form. 275) should then be given. If there be much tenderness or pain 
in the hypochondria, leeches may be applied to these regions or to the 
margin of the anus. The headache may be relieved by a bladder of ice 
or a stream of iced water. Perspiration should be elicited by saline 
diaphoretics. 

We must carefully notice the quantity of the urine. If it be little, 
we must resort to the treatment required in such a case (see Suppres- 
sion of Urine). During the intermission great attention must be paid 
to the action of the bowels ; the secretion of the liver should be en- 
couraged, and, if excessive, controlled, but not stopped. An occasional 
dose of calomel will be of much service if dysenteric symptoms be 
absent. Tenesmus requires relief by opiate, suppository, or enemata. 

Quinine and acids, in full doses, should be persevered in for a time in 
ordinary cases. 






( 307 ) 



CHAPTER IV. 

EXANTHEMATA— ERUPTIVE FEVERS. 

Definition. — Contagious diseases, attacking a person, for the most 
part, only once, beginning with fever, and followed, after a short and 
nearly definite interval, by cutaneous eruptions. 

Variola Small-pox. 

Vaccina ....... Cow-pox. 

Varicella Chicken-pox. 

Rubeola ...... Measles. 

Scarlatina Scarlet Fever. 

Diphtheria Diphtheria. 

Pestis Plague. 

VARIOLA— SMALL-POX. 

Definition. — A contagious and infectious disease, setting in with 
severe febrile symptoms, followed by an eruption which passes through the 
successive forms of papule, vesicle, and pustule in about eight days. 

Varieties. — 1. Variola discreta, distinct small-pox. 2. Variola 
connuens, confluent small-pox. 3. Varioloid, modified small-pox. Sy- 
denham and Frank have also described a w Variola sine eruptione." 

1. VARIOLA DISCRETA — DISTINCT SMALL-POX. 

Symptoms. — Rigors, lassitude, headache, severe lumbar pains, extreme 
weakness in the back, and a white furred tongue, nausea, vomiting, and 
tenderness of the epigastrium. Drowsiness and sometimes coma, and in 
infants convulsions or epileptic fits, are occasionally present. The symp- 
toms are followed by inflammatory fever, with full frequent pulse, hot 
and dry skin, diminished secretions, restlessness,, and, in some cases, de- 
lirium. The patient continues in this condition until the eruption, which 
is often preceded by sweating, appears. A diminution of the fever occurs 
at this time. 

At the end of forty-eight hours from the first occurrence of rigors, 
but sometimes earlier, and sometimes as late as the fourth day, the 
eruption appears on the face and forehead as distinct minute papulae, 
about the size of a pin's head, sensibly elevated above the surface of the 
skin, and feeling like small shot beneath the ringer. 

During the third day, or the third and fourth days, the eruption 



308 VARIOLA. 

extends over the rest of the face, and travelling downwards, successively 
involves the neck, shoulders, arms, and hands, trunk, legs, and feet. It 
is usually most abundant on the exposed parts of the body. On the 
covered parts the papules are rose-coloured. 

About the jifth day, a minute circular vesicle, depressed in the centre, 
containing a colourless fluid, and surrounded by an inflamed areola or 
margin, may be seen on the top of each pimple. The eruptive fever now 
rapidly declines. 

About the sixth day, there is some swelling of the throat, with diffi- 
culty of swallowing, hoarseness, and a flow of viscid saliva. These 
symptoms arise fiom the extension of inflammation, or of the eruption 
itself, to the lining membrane of the mouth and fauces, where it can be 
seen in the foim of small round white spots. The eyelids, the prepuce 
of the male and labia of the female, are similarly affected. 

Ey the eighth day, the central depression has disappeared, the areola 
has attained its full size, and the contents of the vesicles have become 
purulent. The face swells ; the eyelids are often so enlarged as to close 
the eyes ; and the mouth, nose, and fauces are covered with pustules. 

By the eighth or ninth day, the pustules have attained their full size, 
and are marked by a brown central spot. The inflammatory areola sub- 
sides, the swelling of the face disappears, and the hands and feet begin to 
swell. 

After this time the pustules break, and their contents ooze out, and, 
drying on the surface, form crusts, which in a short time fall off, and 
leave the skin beneath of a purplish-red colour, which often persists for 
weeks. The swelling of the hands and feet gradually subsides, and about 
the seventeenth day the patient is convalescent. In the more severe cases 
permanent white scars are left upon the skin of the face, and of the 
exposed parts of the body. 

The period occupied by the change from pimple to pustule is called the 
period of maturation. At different stages of this process, according to 
the amount of eruption, but generally as early as the eighth day, secon- 
dary fever sets in, characterised by extreme restlessness, sleepless nights, 
a frequent and quick pulse, a dry brown tongue, scanty and high-coloured 
urine, and frequently by delirium, especially at night. The bowels are 
usually constipated, sometimes obstinately so. 

2. VARIOLA CONELUENS — CONFLUENT SHALL-POX, 

5YMPTOMS. — Continent small-pox differs from the distinct form only 
in degree. The eruptive fever is more intense, and increases from the 
first appearance of the rash to the period of maturation. The secondary 
fever is also moie severe, and often assumes the typhous character. Coma 
and delirium are more frequent concomitants ; and severe diarrhoea some- 
times sets in. 

The eruption is also irregular in its appearance and progress. It is 
usually preceded by a led efflorescence upon the swollen skin, from which 
the pustules emerge on the second day in the form of small red points. 
Maturation takes place earlier ; but the pustules, instead of being glo- 






SMALL-POX. 309 

bular, are flat and irregular, and sometimes contain, instead of pus, a 
brownish ichor. The inflammation extends to the subjacent cellular 
membrane, and sometimes ends in extensive sloughing. The swelling of 
the face and salivation commence early, and rise to a great height. The 
fever, though it generally undergoes a slight remission, does not cease, 
upon the appearance of the rash ; and about the ninth day it suffers a 
remarkable exacerbation, and in some instances all the w orst symptoms 
of the typhous condition supervene. The eruption assumes a dark livid 
or black hue ; petechia?, and passive haemorrhages, bloody urine or dysen- 
tery, make their appearance ; there are coma, convulsions, and sordes on 
the lips and teeth, and the patient is often carried off on the night of 
the eleventh day. In cases of recovery, the scars are much deeper and 
more extensive than in the milder form. 

3. VARIOLOID — MODIFIED SMALL-POX. 

Small-pox may be greatly modified in its severity, and otherwise 
changed in character by two causes: — Vaccination, and a previous 
attack of the disease. 

Small-pox modified by a previous attack, or by vaccination, diners in 
several respects from the disease as it occurs in unprotected persons, 
The principal points of distinction are the following: — The eruptive 
fever, though often extremely intense, generally continues during only 
one day. The patient often complains of some indisposition in the after- 
noon, passes an extremely restless night, and finds the eruption out in 
the morning. The first places in which it makes its appearance are 
generally the wrist and alae of the nose. A pimple appearing in the 
latter situation, will often give the clue to the nature of the disease. 
The eruption itself runs a shorter course, is rarely confluent, and presents 
none of the uniformity of the regular disease. A few of the pustules, 
though small, are regularly formed, and present the central depression. 
Several of the pimples do not pass to the form of vesicles, and the 
vesicles themselves shrivel and dry up (Kom-pock), or they are un- 
usually persistent, and from their transparent appearance are called 
Pearl-pock. All the stages of the eruption may be seen on the body at 
the same time, and all of them imperfect. As soon as the eruption 
appears, the patient is well, unless it happen to be sufficiently extensive 
to give rise to secondary fever. 

Cause. — A specific poison, emanating from persons labouring under 
the disease, or from clothes or other articles worn or used by them ; or 
implanted by the introduction of the variolous matter into the system 
by inoculation, or by the application of the scab. 

Prognosis. — Favourable . — The pustules distinct ; the march of the 
disease regular ; the subject healthy. The period of childhood and youth. 
The modified form of the disease. Unfavourable. — The confluent form ; 
the fever assuming the typhous condition, and the pustules becoming 
flattened, livid, or interspersed with petechias. The sudden disappear- 
ance of the rash, with subsidence of the swelling of the face or extremities, 
and depression of the pustules, followed by great prostration of strength, 



310 VARIOLA. 

universal pallor, great anxiety, oppression at the chest, syncope, convul- 
sions, coma, or delirium. A sudden increase of frequency in the pulse, 
great dyspnoea. Excessive vomiting before the rash, and continued after 
its appearance. Blood in the urine, and other secretions. Complications 
with visceral disease, such as inflammatory affections of the brain, of the 
throat, larnyx, or lungs, or of the alimentary canal, and suppurations in 
these viseera, or in the joints. Infancy, and advanced age. 

In general, the fate of the patient is determined in the interval between 
the eleventh and seventeenth day, but death may take place during the 
primary fever. The crisis of the secondary fever is occasionally accom- 
panied by diarrhoea. 

Sequels. — Abscesses, ulcers, boils, suppuration of the glands of the 
neck, sloughing of the skin, erysipelas, suppuration of the joints, result- 
ing in permanent lameness; ophthalmia, followed by blindness from 
opacity of the cornea ; deafness, following suppuration of the internal 
ear ; suffocation from swelling of the glottis ; inflammation of the 
serous membranes of the chest and abdomen ; pleurisy, terminating in 
empyema ; inflammation of the lungs ; haemoptysis ; hsematuria, in- 
flammation and suppuration of the kidneys ; in females, menorrhagia ; 
in pregnant women, abortion. Melancholia followed by mania may 
occur at this period. During convalescence, patients may be attacked 
with other prevalent diseases, such as typhus fever, erysipelas, and 
hospital gangrene. 

Morbid Anatomy. — On the skin, the eruption already described. 
On the conjunctiva of the eye, and on the lining membrane of the air- 
passages, on the mouth, tongue, nostrils, palate, and fauces, on the pre- 
puce and labia, small patches of false membrane, or of detached epithe- 
lium, or denuded spots of mucous membrane, or actual pustules. In 
rare cases, these appearances extend into the bronchial tubes and through 
the whole length of the intestines. There are traces of inflammation in 
various internal organs ; the texture of the viscera is often softened, and 
putrefaction makes rapid progress. 

Diagnosis. — The suddenness of the attack, the intense pain in the 
head, back, and loins, the sickness, the absence of the local affections of 
the other severe exanthemata, the prevalence of the disease at the time, 
and the exposure to contagion, afford a probability in favour of small- 
pox. The regular succession of appearances, and of changes in the erup- 
tion, afterwards renders the distinction easy. Before the appearance of 
the eruption the diagnosis is often exceedingly difficult. A typical case 
may be mistaken for relapsing fever (page 305) ; a modified form may 
be difficult to distinguish from enteric fever (page 301). The primary 
fever may be accompanied by profuse sour-smelling perspiration, asso- 
ciated with general muscular pains, amongst which the lumbar pain is 
not particularly regarded ; and we are liable to mistake the disease for 
rheumatic fever ; and it is rheumatic fever, without doubt, but there is 
small-pox superadded to it. In the case which has suggested these 
remarks, profuse sour-smelling sweat continued for forty-eight hours 






SMALL-POX. 311 

before the rash appeared ; the muscular pains remained for two days 
longer. In another case the eruption was preceded by a copious, finely 
maculated, fiery crimson petechial rash, overspreading the trunk and 
upper parts of the limbs, and confluent at the flexures of the aims and 
thighs into vivid crimson patches, surrounded by discrete but crowded 
petechias. The rest of the skin was of a dusky crimson colour, and the 
surface was intensely hot. Two rose-coloured papules were noticed on 
the chest : the lumbar pain was intolerable. Twelve hours afterwards 
the eruption began to appear ; and, although it was far disproportionate 
to the petechial rash, the disease was of the confluent variety. At the 
outset such a case may be mistaken for typhus. 

It is sometimes difficult to distinguish the papular eruption of small- 
pox from an acute attack of syphilitic lichen. In the early stage of the 
eruption of variola, the papulae on the alas of the nose and upper lip 
give a highly characteristic appearance to the countenance. 

Mortality. — This is influenced by three conditions, viz., the age of 
the patient, the neglect of vaccination, and the severity of the disease. 
Childhood and old age both predispose to a fatal issue. According to 
Mr. Marson, patients of all ages die at the rate of 50 per cent, in the 
confluent form; 8 per cent, when the disease is semi-confluent ; and of 
4 per cent, in the discrete variety. 

Annual fluctuation considerable, e. g., in 15 years (from 1840 to 
1854) the number of deaths in London, in a million inhabitants, was as 
high as 890 in 1844, and as low as 225 in the year preceding, and only 
87 in 1853. This fluctuation is in part due to recent legislation. 

Laws of Infection. — Communicated by contact or through the 
air, by the living and dead body ; by the contents of the vesicles and 
pustules ; by the dried scabs ; or by substances imbued with the vario- 
lous matter. Infecting distance considerable — from 30 to 50 feet, or 
more. The period at w T hich a patient begins to be able to communicate 
the affection, and at which he ceases to be dangerous to others, has not 
been ascertained. It rarely occurs twice in the same person ; about one 
per cent, it is believed are liable to a second attack. May attack the 
foetus in utero. Period of incubation. — Usual duration, twelve days ; 
limits, ten to sixteen days. 

Treatment. — Before the appearance of the eruptive fever, the 
treatment will be the same, whatever may be the nature of the impend- 
ing disease. An emetic (Form. 220), followed by a brisk saline aperient 
(Form. 259), to remove any offending matter from the alimentary canal ; 
local bleeding in the plethoric ; the antiphlogistic regimen, if inflamma- 
tory symptoms run high ; stimulants in extreme nervous depression ; 
opium in great nervous irritability ; bleeding and stimulants in conges- 
tion, to promote reaction, and to relieve the circulation. During the 
eruptive fever the febrile symptoms, if considerable, are to be moderated 
by exposing the body of the patient to a cool atmosphere, by frequently 
administering cold diluent fluids, as lemonade, cold toast-w r ater, soda- 
water, &c. ; at the same time administering saline aperients, so as to 



312 VAKIOLA. 

keep the bowels loose. Cold affusion may also be employed with advan- 
tage when there is much heat of skin; but cold or tepid sponging, 
limited to the hands and arms, is to be preferred. 

After the appearance of the eruption, the indications are : 
I. To moderate the fever when violent. II. To support the strength 
when deficient. III. To subdue local inflammation and relieve occa- 
sional symptoms. 

I. As the fever at once subsides on the appearance of copious perspir- 
ation, our object must be to promote it. After an emetic we may give 
stimulant diaphoretics ''Form. 229 or Form. 228), every four hours. 
A full dose of opium will generally be required at bedtime. The apart- 
ment must be kept cool and well ventilated. 

II. If the patient's strength fail, he must be supported by tonics or 
stimulants, according to the degree of the existing debility. Quinine, 
or the tonic infusions, may be prescribed in the lesser degrees of weak- 
ness, wine and ammonia in the greater. If the patient is irritable and 
restless, as well as weak, opium may be combined with the tonic or 
stimulant. 

III. Ophthalmia, if it be severe, will require leeches to the temples. 
In milder cases, solution of nitrate of silver (gr. v — Ji) should be ap- 
plied. Olive oil. cold cream, or simply tepid water, are grateful appli- 
cations to the swollen and irritable face. 

If the throat be attacked, and there be difficulty in swallowing, leeches 
may be applied to the neck, and gargles of infusions of roses used. 

Determination to the head or chest, or other viscera, must be treated 
by the remedies applicable to idiopathic inflammation of the same parts. 
Blisters and counter-irritants must be cautiously employed, especially 
in those cases where the skin is already the seat of inflammation. 

Obstinate vomiting, w T hich sometimes proves both troublesome and 
dangerous, is best treated by effervescent salines, with a few drops of 
laudanum. If there be tenderness at the epigastrium, a warm bread-and- 
water poultice may be applied, preceded, in severe cases, by a few leeches. 

If the febrile symptoms indicate a typhous tendency, the treatment 
recommended in that stage of continued fever should be resorted to. 

If, after the eruptive fever has passed away, the patient surfer from 
profuse sweats, a cool regimen, and the dilute mineral acids in combin- 
ation with tonics (Form. 137), should be given. 

Diarrhoea, when excessive, is to be checked by small doses of lauda- 
num (3 — 5 drops), with chalk mixture, or by the Pulvis creta? co. c. 
Opio, in doses of ten grains or a scruple every three or four hours. 

When the eruption suddenly recedes, or the pocks sink and shrink, 
and alarming symptoms, such as rigors, convulsions, or delirium, super- 
vene, recourse must be had to depletion and counter-irritants — leeches 
to the temples, blisters to the nape of the neck, and sinapisms to the feet 
and legs. The cold douche applied to the head whilst the body is in 
a warm or vapour bath, may be used with great benefit. 

The secondary fever requires the treatment of continued fever of the 
same type and degree of severity. When much irritation is present full 
doses of opium are indicated. 






cow-pox. 313 

In favourable cases little treatment is required beyond an occasional 
saline aperient, and the avoidance of excess in diet. 

In all cases of small-pox the warm bath should be used repeatedly 
during the convalescence. 

Prevention of pitting. — Various means have been recommended for 
this purpose. All of them consist either (1) in protecting the parts 
from the air ; or (2) in letting out the contents of the vesicles before 
the change from lymph to pus ; or (3) in exciting common, in place of 
specific, inflammation. 

1. To protect the skin from the air, and to give support to the swollen 
skin, a mixture of equal parts of collodion and castor-oil may be painted 
over the face in males, and the face, neck, and arms in females. 

2. Puncturing the full vesicles with a fine needle, and absorbing their 
contents with soft cotton, is an effectual method, but it is very tedious. 

3. Nitrate of silver in substance, or in strong solution, applied to the 
pustules, is also advantageous. Tincture of iodine has been substituted 
for the solution of lunar caustic, and with benefit. 



VACCINA— COW-POX, VACCINATION. 
SYNONYMS. — Vacciola, vaccinia, kine-pox, vaccine disease. 

The benefits conferred on mankind by the discovery of vaccination, as 
a preventive of small-pox, are now universally admitted. 

Vaccination. — Mode of performing the operation. — Three or four 
punctures are to be made near each other, in one or in both arms, about 
the insertion of the deltoid muscle. The skin being made tense, a sharp 
lancet is to be inserted obliquely downwards, so as to produce a trace of 
blood. The lancet must be perfectly clean and free from grease, in order 
that the vaccine matter may adhere to it. When the matter is taken 
from the arm of another child, the lancet should be dipped in the lymph 
of the vesicle, and then inserted in the punctures. If preserved on slips 
of glass, or on points, it must be first moistened by the breath. 

description of the areola. 

When the operation has been properly performed, the course of the 
eruption is somewhat as follows : — 

Second day. — Small red spots appear, which feel hard, but, when 
viewed with a magnifier, are seen to be vesicular. Third or fourth 
day. — The spots are larger and more perceptible. Fifth day. — Small 
pearly circular or oval vesicles corresponding to the punctures, and con- 
taining a minute quantity of transparent fluid. Eighth day. — The 
vesicle has attained its perfect form and full size, with depressed surface 
and raised margin. On the evening of this day the vesicle begins to be 
surrounded by a circular rosy areola, and the skin for some distance 
round it is tense and painful. There is also slight febrile disturbance. 
Ninth and tenth days. — The areola increases, and is often accompanied 



314 VACCINA. 

by extensive erythema of the arm, and sometimes by a liehenous erup- 
tion over the whole body. Eleventh day. — By this time the vesicle, if 
it have not been opened, has burst, the areola has begun to fade, the 
centre of the vesicle is covered with a brown scab, which first hardens 
and blackens, and about the twentieth day falls off, leaving a deep mark, 
or indentation on the skin, of a circular form, with as many pits as there 
were cells in the vesicle, and proportioned in size to the previous inflam- 
mation. Unless all these appearances are observed the vaccine disease 
has been imperfectly communicated, and re-vaccination is absolutely 
necessary. 

Precautions. — The best time for taking the lymph is from the fifth 
to the eighth day ; after this time it cannot be depended on. The disease 
will not be properly communicated if there be a chronic eruption on the 
arms ; if scarlatina, measles, or other cutaneous disease supervene ; if 
dentition, disordered bowels, or any other malady be present ; or if any 
cause, such as friction or injury, disturb the vesicle. Sometimes boils, 
pustules, and leprous and impetiginous eruptions succeed the vaccine 
disease ; but this seldom happens when the child's health is good at the 
time of vaccination. Such eruptions are readily cured by mercurial 
alteratives and gentle aperients. 

Infants may be vaccinated at any time after the sixth week. The age 
of three months is to be preferred, if the child be healthy. 

As a rule, vaccination should be repeated every seven years up to or 
a little beyond the middle period of life. Re-vaccination may, however, 
be generally assumed to be unnecessary so long as the person can show 
three well marked excavated scars. As it may be practised without in- 
convenience, it may be well to resort to it when epidemics prevail, to 
insure protection or to allay the fears of timid persons. 

The best argument for 1 e- vaccination is the result of that operation 
in the Prussian army. In the year 1841 nearly 45,000 soldiers were 
re* vaccinated, and though before that time varioloid disease was very 
prevalent in the barracks, only eight cases occurred afterwards. 

As it is highly important that the amount of protection afforded by 
vaccination should be understood, the following tables have been con- 
structed : — 

EPIDEMIC IN SCOTLAND, 1818-1819. DR. JOHN THOMPSON. 

Unnrotected Small-pox Small- pox after 

unprotected. SfcCond time Vaccination. 

Cases ... 205 71 310 

Deaths ... 50 3 1 

Proportion . . 1 in 4 1 in 23 1 in 310 

The following table, reduced to an uniform scale of 15,000, is founded 
on the facts recorded by M. Favart during an epidemic of small-pox which 
took place at Marseilles in 1828. The estimated population under 30 
years of age was 40,000, of whom 30,000 had been vaccinated, 2,000 
had had casual small-pox, or small-pox by inoculation, and 8,000 were 
unprotected. 



CHICKEN-POX. 315 
MARSEILLES. — EPIDEMIC OF 1828. — ESTIMATED POPULATION, 

40,000. 

Unprotected. *£™^ Vaccinated. 

Estimated number . . 15,000 15,000 15,000 

Attacked .... 7,500 150 2,000 

Died 1,875 30 10 

Proportion attacked . 1 in 2 1 in 100 1 in 15 



Proportion of deaths to\ 
attacks 



1 in 4 1 in 5 1 in 100 



In the Small-pox Hospital, during the 11 years 1841-1851, there 
were 4,091 admissions with small-pox, distributed as follows : — 

Patients. Deaths. ^52? 
per cent. 

Not alleging any protection . . , 1,722 629 37 

Alleging prior small-pox .... 36 6 17 

„ vaccination, but no scars . . 166 56 34 

,, vaccination, and scars . . 2,167 147 7 

The inference to be drawn from these facts is, that vaccination, though 
a less complete protection against attacks of small-pox than inoculation 
or a previous attack of the disease, is the best existing protection against 
a fatal attack. 



VARICELLA— THE CHICKEN-POX. 

Synonyms. — Swine-pox, Bastard-pox, Gland-pox, Crystalli. 

Definition. — A contagious and infectious disease ushered in by 
slight febrile symptoms, followed by a vesicular eruption which gene- 
rally runs its course in five days. 

Symptoms. — Within twenty-four hours after slight symptoms of 
fever, such as lassitude, loss of sleep, wandering pains, and loss of 
appetite, an eruption appears ; first on the back, consisting of small 
reddish pimples, much resembling the first appearance of small-pox. 
On the second day, the red pimples have become small vesicles, contain- 
ing a colourless fluid, and sometimes a yellowish transparent liquor. 
On the third, the vesicles arrive at maturity. Soon after, the fluid be- 
comes extravasated by spontaneous or accidental rupture of the tender 
vesicles, or they collapse and dry ; whichever happens, a thin dark- 
brown or yellowish scab is formed. Pus is never formed, as in variola. 
Generally before the fifth day the eruption disappears, without leaving 
behind it any cicatrix or mark. 

Cause. — Predisposing, Infancy and childhood.' — Exciting. Con- 
tagion. 

Diagnosis. — From variola. By the slight fever ; by the short in- 



316 RUBEOLA. 

terval (24 hours) between the first symptoms and the appearance of the 
rash ; by the pimples first appearing on the Lack ; by the form and 
condition of the eruption, which is never pustular nor depressed ; by 
the separation of the scaly scabs about the fifth day, when the eruption 
in variola is only just completed. From modified small-pox by the 
absence of pits from all the vesicles. 

Prognosis. — Highly favourable. 

Laws of Infection. — The infection is less powerful than that of 
the other febrile exanthemata, and the infecting distance probably small. 
The disease, as a general rule, affects the system only once. The latent 
period is probably considerable. 

Treatment. — This complaint seldom requires the aid of medicine. 
Gentle saline aperients may he prescribed, combined with small doses of 
tartar-emetic, if the fever should happen to exceed its usual moderate 
standard. The treatment may be terminated by a warm bath. 



RUBEOLA— THE MEASLES. 

Synonym. — Morbilli. 

Definition. — A continued contagious and infectious fever, com- 
mencing with catarrhal symptoms, and followed, about the fourth day, 
by a peculiar eruption on the skin. 

Varieties. — 1. Rubeola vulgaris; 2. Rubeola maligna ; 3. Rubeola 
sine catarrho. 

1. rubeola vulgaris. 

Synonyms. — Morbilli vulgares ; Morbilli mitiores. 

Symptoms. — The premonitory symptoms are those of catarrh. After 
rigors and flushes, lassitude, heaviness, pain in the head and drowsi- 
ness, there are ringing cough, hoarseness, difficulty of breathing, fre- 
quent sneezing, itching of the face, smarting of the eyes, and swelling 
of the eyelids, with copious secretion of watery fluid from the eyes and 
nostrils ; nausea or vomiting, thirst, furred tongue, frequent pulse, and 
the general symptoms of fever. On the fourth, but sometimes as early 
as the third, or as late as the fifth day, small red circular spots, resem- 
bling flea-bites, appear, first on the iace, neck, and upper extremities, 
then on the trunk, and afterwards on the lower extremities. The three 
crops of the eruption are commonly separated by an interval of twenty- 
four hours. The spots are generally in crescentic clusters, of a deep- 
red colour, do not rise into visible pimples, but are found by the touch 
to project slightly above the surface. Sometimes, however, the spots 
are distinctly papular, and, at the height of the eruption, vesicular. 
About the eighth day, but sometimes as early as the fifth or sixth, the 
colour of the rash begins to fade ; first upon the face, neck, and arms, 
then upon the trunk, and lastly on the legs : and, in a day or two more, 



MEASLES. 317 

the eruption entirely disappears, with a mealy or furfuraceous desqua- 
mation of the cuticle. At this period diarrhoea sometimes sets in. The 
fever and catarrhal symptoms subside at the same time, and the expec- 
toration changes from a transparent mucus to an opaque-whitish or 
yellowish -white sputum. 

The catarrhal and febrile symptoms sometimes subside on the appear- 
ance of the rash ; but in most cases they increase, and are often accom- 
panied by pulmonary symptoms, the cough becomes troublesome, and 
the breathing short, frequent, and wheezy. The stethoscope reveals 
bronchitis more or less diffuse. Pneumonia occasionally supervenes. 

The usual duration of the disease is from nine to twelve days. The 
patient often convalesces very slowly. 

2. RUBEOLA MALIGNA. 

Synonyms. — Morbilli nigri ; Morbilli graviores. 

This form is ushered in by more severe premonitory symptoms, and 
soon assumes the typhous character. The eruption appears early, but 
irregularly, alternately receding and reappearing. It assumes a dark 
or livid hue (rubeola nigra), and is often interspersed with petechia?. 
The fauces are of a dusky-red or claret colour. All the symptoms are 
aggravated ; there is great tenderness in the abdomen, with dark offen- 
sive stools ; delirium is present, the mucous membrane of the air pas- 
sages is gravely affected, croup and severe pneumonia are imminent, and 
the patient may die asphyxiated by the congestion of the lungs, or ex- 
hausted by diarrhoea, or comatose from the severity of the head-affection. 

3. RUBEOLA SINE CATARRHO. 

In rare instances the primary fever and eruption show themselves in 
a mild form, without the accompanying catarrhal symptoms. On the 
other hand, cases are believed to occur in which a fever, resembling 
in character and duration that of measles, takes place with catarrhal 
symptoms, but without the rash. 

Cause. — Predisposing. Infancy and childhood ; but the disease may 
occur at any age. The seasons of winter and spring. — Exciting. A 
specific contagion, of which patients are generally susceptible only once 
during their lives. 

MORTALITY. — This varies in different epidemics from 1 in 3 to 1 in 
40, the average being 1 in 15. Annual fluctuations considerable ; e.g., 
1,122 deaths in London in one million inhabitants in 1845, and only 
249 deaths in 1852. 

Laws of Infection. — The disease spreads by fomites and through 
the air ; it may also be communicated by blood from the arm, or by 
serum from the vesicles mixed with the rash. It very rarely occurs a 
second time. The period of incubation is believed to be from 6 to 16 
days ; and there is reason to think that the disease may be communicated 
during the primary fever. 



318 TREATMENT OF RUBEOLA. 

Diagnosis.- — From Scarlatina by the darker hue of the rash, the 
crescentic arrangement of the patches, and its appearance, as a general 
rule, on or about the fourth, instead of the second day. Also by the 
marked catarrhal symptoms, and the absence of the severe affection of 
the throat ; by its shorter course ; and by its less fatal character. From 
Roseola, by the catarrhal symptoms ; and by the greater severity of the 
fever. From Typhus, see page 293. 

Prognosis. — Generally favourable, excepting in the malignant form. 
— Favourable. The febrile and other symptoms slight; moderate 
diarrhoea ; epistaxis ; early and free expectoration ; a moist skin when 
the eruption appears. — Unfavourable. A high degree of fever; hot 
and dry skin; hurried and difficult breathing; flushed countenance. 
The fever increasing after the appearance of the rash, and assuming the 
form of hectic, or of typhus ; great pain in the head and eyes ; shooting 
pains in the chest; symptoms of pneumonia or cynanche ; convulsions ; 
a rapid and small pulse ; co-existence with whooping-cough ; delirium, 
or coma ; continued diarrhoea or vomiting ; a livid hue of the skin. 

Sequelae. — Pneumonia, oedema of the lungs, pleurisy, croup, bron- 
chitis, phthisis ; diarrhoea, enlargement of the mesenteric glands ; ophthal- 
mia, abscesses in the ear, swelling and suppuration of the parotid, sub- 
maxillary or cervical glands ; aphthae and gangrene of the mucous 
membrane of the mouth ; whooping-cough. 

Morbid Anatomy. — Marks of inflammation in the internal organs, 
especially the air-passages and lungs. 

Treatment. Indications. — I. To diminish inflammatory action. 
II. To relieve urgent symptoms. 

I. The temperature of the room should be about 70° Fahr. and 
uniform, and currents of colder air must be carefully excluded. The 
diet should consist of thin gruel, milk and water, or beet-tea containing 
a little bread or vermicelli. 

The action of the skin should be encouraged, and bronchial or pneu- 
monic irritation alleviated by the application of large hot poultices of 
linseed meal, with or without a little mustard, to the throat and chest. 

The bowels should be freely relieved by an active purgative, such as 
from gr. xv to gr. xl of compound jalap powder. 

When the febrile symptoms run high, and more especially when there 
is a threatening of local inflammation, tartar-emetic must be given in 
nauseating doses, at short intervals. 

II. In milder cases it will be sufficient to administer saline refri- 
gerants and diaphoretics in combination with squills or ipecacuanha 
(Form. 243). 

Lemonade, linseed tea, a decoction of figs in milk, or barley-water, 
should be liberally supplied, as they are grateful to the inflamed mucous 
membrane. Inhalations of steam may be used with advantage. 

If need be, we must administer sedatives to counteract restlessness 
and encourage sleep. A combination of henbane and opium will be 
most suitable for these purposes. 



SCARLET FEVER. 319 

If there be much heat, and dryness of the skin, a hot bath should be 
given. 

Pneumonia, diarrhoea, whooping-cough, or any other complication, 
must be treated according to the urgency of the symptoms. 

The malignant form of the disease must be treated generally, as low 
fever (see Typhus), with special reference to the bronchial affection. 

When the eruption disappears before the proper period, and convul- 
sions, great anxiety, or delirium take place, an attempt must be made to 
restore the eruption to the skin, by the immediate use of the hot bath, 
the application of sinapisms or blisters to the chest and feet, the adminis- 
tration of warm wine and water, ammonia, camphor, aether, or other 
appropriate stimulants. 

During convalescence, the diet should be nutritious, the bowels regu- 
lated, and the dress warm. Great care should be taken to avoid exposure 
to cold, and draughts of cold air. 

Prophylaxis. — The same precautions are required to prevent the 
spread of the contagion, as in the case of other contagious maladies. 
Inoculation with blood taken from the patches, wdth the serum of the 
vesicles, when the eruption is vesicular, or with the secretion of the con- 
junctiva, has been practised with some advantage. The cases which 
have followed inoculation have been mild and favourable. 



SCARLATINA— SCARLET FEVER. 

Definition. — A continued contagious and infectious fever, accom- 
panied by inflammation of the fauces, and by a scarlet eruption on the 
skin, setting-in on or about the second day, and terminating in desqua- 
mation of the cuticle. 

' : Species. — 1. Scarlatina simplex ; 2. Scarlatina anginosa ; 3. Scar- 
latina maligna ; 4. Scarlatina sine eruptione. 

1. SCARLATINA SIMPLEX. 

Symptoms. — This disease is characterised by the slight affection of 
the throat. It sets in with the usual premonitory symptoms of fever 
— viz., cold chills, shivering, nausea, and sometimes vomiting, with 
pain in the head, back, and limbs, thirst, hot skin, frequent pulse, rest- 
lessness, and sleeplessness. On the second day, in most cases, a bright 
scarlet efflorescence is perceptible on the face, nect, and arms, whence it 
extends over the trunk and limbs. At first it consists of innumerable 
red points, which soon coalesce, so that in a few hours the redness 
becomes universal ; but is peculiarly distinct at the bends of the joints, 
on the chest and abdomen, the hips and loins. The skin is rendered 
pale by pressure, but the colour immediately returns. After one or 
two days, the efflorescence again becomes partial, is arranged in large 
irregular patches, and does not disappear on pressure. The skin is per- 



320 SCARLATINA. 

ceptibly rough to the touch, and in some instances is studded with small 
miliary vesicles. The rash generally begins to decline on the fifth, is 
very indistinct on the sixth, and wholly disappears by the eighth day. 
Desquamation of the cuticle generally begins on the parts first affected 
about the end of the fifth day, and soon extends to the entire body. 
The cuticle separates as a scurf from the trunk and limbs, and in large 
scales from the hands and feet. The desquamation is often accompanied 
by great itching, irritation, and tenderness. 

The eruption is preceded or accompanied by a sore throat, and some 
difficulty of swallowing ; and, on inspection, the tonsils are found slightly 
enlarged and inflamed, and coated with a white tenacious mucus. The 
eyelids, lips, edges of the tongue, soft palate, pharynx and nostrils, are 
also of a red colour. The papillae of the tongue are elongated, and 
project as bright-red points through the white mucus which covers its 
surface ; or the whole tongue is of a bright-red colour with prominent 
papillae. In the first case it resembles a white strawberry ; in the 
second a red one. 

The fever does not abate on the appearance of the rash, but subsides 
with it, leaving, in most cases, great debility behind it. The pulse is 
generally very frequent (120 or 130), and the skin very hot (105°, 
106°, and even 112° Fahrenheit). There is generally some increase of 
fever at night, with slight delirium, even in favourable cases. The 
bowels are frequently confined, and nausea and vomiting are not very 
uncommon. The urine is often scanty and high-coloured, and, in the 
decline of the disease, generally contains albumen. 

Although the eruption in scarlet fever usually occurs on the second 
day, there are many exceptions to the rule. On the one hand there are 
cases in which the rash appears much earlier than the second day, as in 
a lad of sixteen, who felt ill for the first time at five o'olock in the 
evening, and had the eruption full out upon him before twelve o'clock 
at night. On the other hand, during the prevalence of scarlet fever, 
cases are constantly occurring in which there is slight sore throat, and 
a suspicious appearance of tongue, with little disturbance of health for 
three, four, or five days, at the end of which time the eruption makes 
its appearance, and the disease generally runs a mild course. These 
cases present some difficulty ; but however slight the other symptoms 
may be, there is always during this latent period a very frequent, full, 
and peculiarly compressible pulse. Whenever this pulse exists, some 
febrile disease (and scarlatina, if rife at the time) may be confidently 
looked for. (G.) 

2. SCARLATINA ANGIXOSA. 

Symptoms. — Those of scarlatina simplex, but in an aggravated form, 
with a more severe affection of the throat and parts adjacent. 

The submaxillary glands are enlarged and painful to the touch ; the 
soft palate, uvula, tonsils, and pharynx, as far as the eye can reach, are 
of a florid red colour, the tonsils and soft palate much swollen, and the 
uvula enlarged and lengthened. A thick mucus collects at the back of 
the throat, and proves very troublesome to the patient, and specks are 



SCAELET FEVER. 321 

often observed resembling the sloughs in cynanche maligna ; yet ulcera- 
tion seldom takes place, and when it does occur, is superficial. Smooth 
yellow patches of fibrous exsudation frequently form over the inflamed, 
excoriated, or ulcerated tonsils or pillars of the fauces, in all respects 
resembling the exsudation of diphtheria. The mouth is opened with 
difficulty, there is great pain in swallowing, and liquids often return 
through the nostrils. The tongue is very red, and its papillae are very 
prominent. The inflammation may extend to the mucous membrane of 
the nose, and through the Eustachian tube to the ears, followed by thin 
purulent discharge from those parts. The skin is of a deeper colour, 
and the eruption spreads more rapidly over the surface. 

Not unfrequently, after a few days' amendment, an unaccountable 
languor and debility supervene; the pulse is accelerated ; the sleep is 
disturbed; the appetite is lost; the secretion of urine is nearly sup- 
pressed ; and drop>ical effusions take place into the limbs, abdomen, or 
chest, or in several parts of the body at the same time. 

3. SCARLATINA MALIGNA. 

Symptoms. — The tonsils, though less swollen than in scarlatina angi- 
nosa, are of a deeper red colour, and soon become the seat of rapid, 
extensive, and deep ulcers, interspersed with dark sloughs, which are 
detached slowly, leaving deep lagged sores, which heal with difficulty. 
Ashy ulcers also form on the interior of the cheek. The inflammation, ex- 
tending into the nostrils, causes a thin acrid discharge, which excoriates 
the lip and inflames the parts over which it flows, and the salivary 
glands are much swollen and inflamed. The eruption appears late, in 
irregular patches of a paler colour, which sometimes disappear suddenly. 
The other symptoms are those of the typhous form of continued fever. 

4. SCARLATINA SINE ERUPTIONE, OR S. LATENS. 

Sometimes the disease assumes so mild a form as altogether to escape 
detection till some sequela, such as general anasarca, appears to declare 
that the slight indisposition, " a feverish cold," was an attack of scar- 
latina. We must be careful not to overlook such cases, as, from want of 
proper nursing and precautions, the consequences they entail are as bad 
as, or even worse than, those of a severe form of the disease. 

It is not uncommon for those who have had scarlet fever in its usual 
form, when again exposed to the contagion, to have the characteristic sore 
throat succeeding the usual premonitory symptoms, but no eruption. 
Desquamation of the cuticle, however, occurs in some of these cases, 
where no distinct rash has appeared on the skin. Such persons are 
capable of communicating the common type of the disease. 

Duration of Scarlet Fever. — In cases of ordinary severity, the 
first state (from the commencement to the appearance of the rash) 
twenty-four, forty-eight, or seventy-two hours; the second stage (from 
the appearance of the rash to its subsidence) from six to eight days, and 
the third stage (from the disappearance of the rash till the recovery of 

Y 



322 SCARLATINA. 

the patient) from a few days to two or three weeks. Entire duration 
of the disease from eight days to thirty days, or more. 

Sequelae. — Acute desquamative nephritis, with anasarca, and occa- 
sionally with other dropsical affections, such as ascites, hydrothorax, 
hydrocephalus, and hydropericardium. These diseases often follow the 
mildest attacks. The other sequelae show themselves mostly after attacks 
of scarlatina anginosa or maligna. They are the following : — Pain and 
swelling of the larger joints, with formation of serum, or pus ; scrofu- 
lous affections ; discharge from the nostrils ; discharge from the ears, 
and permanent deafness ; suppuration of the glands of the neck ; trouble- 
some ulcers of the tongue, pharynx, or epiglottis; croup; inflammation 
of the eyes and eyelids ; inflammatory arlections of the internal viscera 
or of their serous investments ; abscess of the testis ; mortification of 
the face, lower extremities, and pudenda ; also of portions of the integu- 
ments on which the patient has lain; troublesome diarrhoea. Abscess 
of the brain is a remote result of some cases of scarlatina which have 
been followed by pain and suppuration of the ear. The membrana tym- 
pani and small bones of the ear are destroyed, suppuration is set up in 
the cancellous tissue of the petrous bone, and necrosis occurs, and the 
neighbouring veins may become implicated and lead to purulent deposits 
in the brain, indicated by intolerable pain in the corresponding part of 
the head, quickly followed by coma, preceded or not by convulsions. 

Terminations. — In complete recovery. In complete recovery after 
one or more of the foregoing sequelae. In imperfect recovery, the patient 
suffering from the effects of one of these sequelae. In profound coma on 
the first appearance of the rash, followed by death in twenty-four hours, 
as if from the effects of a strong narcotic poison ; violent delirium during 
the first five days of the fever. In death on the first, second, or third 
day, with incessant vomiting, or diarrhoea, or the two combined. In 
death at more advanced periods of the disease from exhaustion, or from 
the effect of any of the sequelae. 

Post-mortem Appearances. — Ulceration and purulent collections 
in the tonsils, with traces of inflammation extending from the fauces 
through the oesophagus, and sometimes through the whole alimentary 
canal. Congestion or inflammation of the kidneys. Inflammation and 
swelling of the joints. If the patient die from delirium and coma, great 
congestion of the vessels of the brain will be found. 

Causes. — Predisposing, Bad food and water. — Exciting. A spe- 
cific contagion. 

Mortality. — The deaths in London in a million of the population 
vary from 350 to 2130, and average 900. The fluctuations from year 
to year are considerable, and the rate of mortality in different years has 
varied in the following proportions : 1,2, 3, 6, 10, 16, and 25 per cent. 

Laws of Infection. — The disease spreads by contagion and through 
the air ; its infecting distance is considerable ; it lingers in the same 



SCARLET FEVER. 323 

place longer than other infectious diseases ; it rarely attacks the same 
person more than once, but may occur a second and even a third time ; 
it may be communicated by inoculation of the contents of the vesicles 
which are sometimes blended with the rash ; it is thought to be com- 
municable before the appearance of the rash, and for as much as three 
weeks after its disappearance. It prevails constantly. 

Period of Incubation. — From a few hours, or two or three days, 
to ten days or a fortnight. It is sometimes stated to be fire days. 

Diagnosis. — Scarlatina may co-exist with Enteric fever. From 
measles it is distinguished by the absence of cough, sneezing, and coryza : 
by the affection of the throat ; by the peculiar appearance of the tongue ; 
by the brighter hue and greater extent and less-defined form of the 
eruption ; by the occurrence of the rash in most cases on the second 
instead of on the fourth day. The great frequency of the pulse and the 
high temperature of the skin are also highly characteristic of scarlet 
fever, as are secondary dropsy, affections of the joints, and mortifications. 
From most cutaneous disorders by the extent of the eruption, the sore 
throat, and the fever. A supposed hybrid of scarlet fever and measles 
has been described under the term BotJteln. It is scarlatina plus cough, 
hoarseness, and lachryrnation ; symptoms which assim il ate the disease 
to measles, but which are due to the presence of scarlatinal eruption on 
the mucous membranes. The eruption on the skin is usually excessive 
in this form of the disease. 

Some cases of scarlatina which soon lapse into profound coma may be 
mistaken for narcotic poisoning, but the skin in such cases of fever is 
usually as red as, or even redder than, a boiled lobster. 

For the distinction between Scarlatina and Diphtheria, see Diphtheria. 

Prognosis. — Favourable symptoms. The concomitant fever purely 
inflammatory, and slight affection of the throat ; remission of the febrile 
symptoms, and of the affection of the throat, upon the appearance of the 
eruption ; epistaxis ; diarrhoea ; or other critical discharge. [In one case, 
I have known all the threatening symptoms pass away, after a profuse 
discharge of mucus from the nostrils (G.).] Unfavourable symptoms. 
Early nausea and vomiting ; the fauces of a dark -red or purple colour, 
without swelling ; ash-coloured or brown specks, soon becoming ulcerated, 
or terminating in gangrene [cynanche maligna) ; a brown tongue ; great 
prostration of strength ; early occurrence of delirium ; coma ; high fever 
after the period of desquamation ; dyspnoea, and stridulous voice, indi- 
cating the extension of the disease to the larynx and trachea ; acute pain 
in the ear, with deafness and purulent discharge ; acrid discharge from 
the nose ; obstinate dryness of the skin ; a fresh efflorescence and increase 
of fever; a sudden disappearance of the rash, or a livid hue. The 
pregnant, and especially the puerperal state, and teething. 

A favourable convalescence may be expected when the pulse falls much 
below its natural frequency in health ; and a marked improvement is 
generally indicated by a fall of the pulse at night as compared with its 
frequency in the morning. A frequent pulse continuing when the urgent 



324 SCARLATINA. 

symptoms have subsided would lead us to anticipate a lingering conva- 
lescence or the occurrence of secondary symptoms. (G.) 

Treatment. — A moderate and equable temperature, about 60° Fahr. ; 
a clean and spacious apartment ; a light diet without animal food ; cool- 
ing acidulated liquors for common drink, and the saline draught as 
medicine ; gentle aperients, more particularly towards the decline of the 
eruption. The treatment may be advantageously commenced with an 
emetic (Form. 220), followed by a saline aperient, or by a full dose of 
castor-oil. 

If the constitution be robust and there be much fever, we may admi- 
nister nauseating doses of tartar emetic during the first twenty-four hours. 

When the heat of the body is great, and persistent, and the skin dry, 
the patient should be immersed for ten minutes in a hot bath, and saline 
diaphoretics given. 

When severe inflammation of the throat is present, with much ex- 
ternal tenderness, and great difficulty in swallowing, from six to twelve 
leeches may be applied to the angle of the jaw, followed by a large warm 
bread-and- water poultice, and repeated if necessary. In milder cases a 
bread-and-mustard poultice, or stimulating in frictions, applied to the 
same part, are necessary. A strong solution (5 grs. to 3i.) of nitrate 
of silver should be applied twice a day to the inflamed fauces. Acidu- 
lated gargles (such as the compound infusion of roses with an excess of 
acid) may be used to clear the throat ; and if the discharge be offensive, 
gargles of chlorine or permanganate of potash will be required. The 
following is a very useful form : — Dissolve 3ii of chlorate of potash in 
an ounce of water, add 53s. of hydrochloric acid, and afterwards water 
to ^vi. This gargle may be swallowed. At this stage of the disease 
the patient's failing strength often requires the use of 4 or 6 oz. of wine 
daily. The diaphoretics should be persevered with. 

At the decline of the eruption tonics are required, of which quinine 
is the best ; and a nutritious diet w T ith wine, in moderate quantity. 
But if the skin continue diy and hot during desquamation, we must 
induce sweat by the appropriate means. For a full fortnight after des- 
quamation the patient should be kept warm in the house, unless the 
external air be dry and mild. A sudden chill arrests the action of the 
skin and leads to congestion of the kidneys. About the time when des- 
quamation sets in a little albumen is generally contained in the urine, 
and disappears after a day or two. If it persist and increase, we must 
resort to the hot bath, and keep the patient in bed. Scarlatina, which 
assumes at any part of its course the typhous character, is highly dan- 
gerous and requires the employment of tonics, such as mineral acids, 
combined with quinine or bark, and stimulants in large and repeated 
doses, as recommended in typhus fever. When the throat is covered 
with sloughs, stimulating and disinfecting gargles must be used very 
often ; and strong solution of nitrate of silver should be frequently 
applied to the threat. 

Chlorate of potash (a drachm to a pint of water) may be taken as a 
irink in cases of seveie scarlet fever; or it may be taken with hydro- 



, 



DIPHTHEEIA. 6Zo 

chloric acid in the proportions recommended for the gargle, and in Jss. 
doses. 

Complications must be treated on ordinary principles, according to 
the severity of the inflammation and the existing state of system. 
Swelling of the joints is best treated by hot fomentations. Dropsy, 
following scarlatina, must be treated in the usual way. (See Dropsy 
and Renal Diseases.) 

Proper aperients, tonics, nutritious diet, warm clothing, and cautious 
avoidance of exposure to cold or damp, must be employed and observed 
after recovery from this disease. 

Prophylaxis. — As the disease is highly contagious, the same pre- 
cautions are required to prevent it from spreading as are recommended 
in typhus fever. (See p. 294 ; see also the precautions given under 
" Nursing," p. 254.) 

DIPHTHERIA— DIPHTHERIT1S. 

Definition — A contagious and infectious disease, manifested by 
inflammation of the commencement of the alimentary and respiratory 
passages, and accompanied by fibrinous exsudation. 

Symptoms. — The disease invades the system most insidiously, and it 
may be fully developed when the patient is still unconscious of any affec- 
tion of the throat. Generally, however, a little stiffness of the neck, 
soreness of the throat, and slight difficulty of deglutition, are complained 
of, and, on inquiry, we may learn that the patient has been feeling a 
little weak and out of sorts for two or three days. Sometimes there is 
considerable constitutional disorder, indicated by chilliness, nausea, and 
diarrhoea, with mental depression and bodily weakness. The skin may 
be hot and dry, or cool and bathed in perspiration, or natural. The 
pulse varies accordingly. On examining the back of the mouth, the 
isthmus of the fauces and tonsils, altogether or in part, are seen to be 
swollen and of a dark claret colour, and, sooner or later (in from twelve 
to forty-eight hours from the commencement of throat affection), a 
smooth, tough, yellowish-grey, thickish layer of lymph, resembling 
wetted felt or washleather, is formed over a portion of the inflamed and 
dusky surface. Sometimes a tonsil is the primary seat of the exsuda- 
tion, whence it spreads to other parts. Sometimes the soft palate or 
one of its arches is the starting-point. But it may first appear on any 
portion of the mucous membrane contiguous to these parts. Occasion- 
ally the exsudation makes its appearance simultaneously at several points. 
Wherever it appears it tends to enlarge, and may spread dow T n the oeso- 
phagus into the stomach, or, what is more dangerous still, it may in- 
volve the mucous membrane of the larynx, and thence extend along the 
trachea into the bronchial tubes. In about three days the whole of the 
inflamed surface is covered with a thick layer of lymph. If there be 
any open ulcers on the skin, they are liable to become covered with 
diphtheritic exsudation. The exsudation is composed of tough fibrinous 
substance; rarely soft and pulpy: detached with some difficulty, and, 



326 DIPHTHERIA. 

when separated, exposing a smooth bleeding surface, on which the exsu- 
dation re-forms in a few hours. We know that the larynx is implicated 
by the change in the voice. It is rough and husky, or there may be 
simply aphonia, and the patient speaks in a whisper. The breathing 
may suddenly become croupy or stridulous, the face livid, the eyes pro- 
minent, the conjunctiva injected, and the supra-sternal and supra-clavi- 
cular depressions sucked inwards. Within a few hours from the acces- 
sion of these symptoms the patient may die suffocated. 

In proportion to the extent of the pharyngeal disease there is pain and 
difficulty in deglutition. In a later stage of the disease pain is absent, 
for the parts have lost their delicate sensation. 

The mucous membrane of the nares participates in the disease, and 
there is a flux of thin muco-purulent matter like that which appears in 
bad forms of scarlatina, but so offensive that the whole atmosphere of 
the room is tainted by it. The breath has the same putrid odour. 

In such grave cases prostration rapidly comes on, and the patient lies 
on his back apathetic, or insensible and muttering. The heart's action, 
which had been feeble, though excited, now begins to fail. The face is 
pallid, the pulse thready, and the patient dies of asthenia. 

During the progress of the disease the urine will in a great many 
cases be found loaded with albumen. 

The duration of the disease varies from forty-eight hours to fourteen 
days. Laryngeal symptoms are usually manifested early ; and when 
the disease is fatal from implication of the larynx, the patient dies within 
a week. In the absence of laryngeal symptoms, death from athenia 
usually occurs during the second week. 

Convalescence commences some time in the second week ; but it may 
be deferred to the beginning of the third. 

Sequelae. — These are much to be dreaded. They are all attribut- 
able to defect or disorder of nervous power, of which the gravest indi- 
cation is feebleness of the heart's action. At a time when convalescence 
appears to be established, and all things seem to be going on well, the 
heart may be losing force. Stimulants may be freely given, and yet 
its action becomes slower from day to day, until the pulsations are re- 
duced to half their normal number, and, the depression still continuing, 
the patient quietly expires. 

Sometimes the whole muscular system partakes of the debility which 
affects the heart : the muscles become too weak to support the body or 
to move the limbs ; the patient cannot use his fingers to button a gar- 
ment or write a letter. This is called paralysis : but is more properly 
termed excessive depression of nerve force. 

More f equently the debility affects only the muscles of deglutition 
and vocalization ; the fauces appear to have lost their sensibility ; solids 
may be swallowed without much difficulty, but fluids are returned 
through the nose. The voice is weak, hoarse, and nasal. In rarer cases 
the special senses are affected, and there is blindness or deafness of one 
or other eye or ear. Disordered sensation, such as tingling in the hands 
or feet, is occasionally noticed. 



DIPHTHERIA. 327 

These symptoms of disordered innervation may set in any time after 
convalescence, even up to six weeks from that event. 

Causes. — Predisposing. Debility. Exciting. A poison, probably 
specific, either generated within the body or external to it ; spreading 
by contagion and infection, and affecting young persons and adults, but 
chiefly children. Old people are remarkably fiee from it. It occurs in 
epidemics separated by long intervals. 

Morbid Anatomy. — In death from laryngeal implication, fibrinous 
exsudations covering the mucous membrane of the larynx, the upper 
portion or the whole of the traehea, and in some cases the bronchial 
tubes to their second or third ramifications. 

In the severe pharyngeal form the oesophagus and parts of the stomach 
may be found reddened and inflamed, or covered with diphtheritic ex- 
sudation. The inflamed mucous membrane and submucous tissue is 
thickened and harder than usual, and sometimes ulcerated ; the soft 
palate and tonsils may be gangrenous. Abscesses occasionally form in 
the cellular tissue surrounding the tonsils and pharynx. The cervical 
glands are enlarged and hard, and the areolar tissue in which they are 
imbedded infiltrated with serum. In death from asthenia we may find 
large fibrinous coagula in the heart or great vessels. 

Diagnosis. — Quinsey is distinguished by its being limited to the 
tonsils. We must distinguish between the yellowish spots of excretion 
from the inflamed gland and fibrinous exsudation. Common sore throat 
is unaccompanied by exsudation, and tends to ulceration. Croup is a 
local disease and restricted almost entirely to childhood, and unattended 
with symptoms of inflammation. Malignant scarlatina and diphtheria 
have so many resemblances, and so few differences, that satisfactory 
evidence of their being distinct diseases is wanting. The chief argu- 
ment — and it is a strong one — in favour of their being distinct, is the 
fact that the one affords no protection against the other. 

Prognosis. — In no disease must our prognosis be more guarded. In 
the early stage we should offer none. If, after a week, there be no 
laryngeal symptoms, we may venture to predict convalescence. A 
robust patient will be less liable to secondary nervous affections than 
one of weakly habit. 

Treatment. — Constitutional. In the absence of strong febrile symp- 
toms, we must adopt the stimulant plan from the first. If the pulse be 
feeble, ammonia and bark should be given every four hours, and half a 
pint of wine or brandy and egg, well diluted, during the twenty-four 
hours, milk or beef-tea being administered in the intervals. 

If the skin be hot, we should, give diaphoretics to maintain it in a 
state of moderate perspiration. If it be cool and clammy, TY\,xx — xxx 
of tincture of perchloride of iron in a wineglassful of water, or a mode- 
rate dose of quinine and acid, may be given thrice a day. Daily action 
of the bowels should be induced by means of saline aperients (Forms. 
256, 264). 

Local. Hot bread-and-mustard poultices to the throat. The appli- 



328 pestis. 

cation by means of a sponge or camel-hair brush of strong solution 
(gr. xl to Ji) of nitrate of silver to the inflamed fauces night and morn- 
ing. Solid nitrate of silver is liable to produce sloughing when appliel 
to the mucous membrane in this low state of inflammation. The occa- 
sional use of the acid chlorine gargle (Form. 71), or of a solution of 
perchloride of iron (3vi of the tincture to Jviii of water), if gargling 
can be effected without much distress. If laryngeal symptoms come 
on, inhalations of hot water simply, or a mixture of vinegar and water, 
will give much relief. A leech may be placed at once over either side 
of the cricoid cartilage. If we have reason to suppose that the exsuda- 
tion is loosely attached to the mucous membrane of the larynx, we may 
give an emetic of sulphate of zinc. If suffocation be imminent, we 
should resort to tracheotomy ; it may prolong life in many cases, and 
will save it in a few. If the exsudation affect the lower part of the 
trachea, little more than palliation can be expected from the operation. 
The subsequent depression of vital power must be combated on general 
principles. 



PESTIS— PLAGUE. 



Definition. — A contagious fever, generally of the continued type, 
accompanied by an eruption of buboes, carbuncles, and peteehiae. 

Symptoms. — The patient is attacked suddenly, or after slight pre- 
monitory rigors, with lassitude, depression, pain and weight of head, 
and giddiness, with an indescribable feeling of anxiety, and extreme 
restlessness and pain referred to the region of the heart. The counte- 
nance is expressive of exhaustion and anxiety, the eye is dull and sleepy, 
the eyelids closed, the mouth half open. The gait is staggering and un- 
certain, like that of a drunken man; the debility extreme ; the head 
falls upon the breast ; the eyes are dull and sunken, the complexion 
dusky. There is nausea, or bilious vomiting, often accompanied by 
diarrhoea ; the urine is scanty, high-coloured, and sometimes bloody ; 
the tongue is swollen, furred, and glistening, but moist and clean 
towards the tip and edges ; pulse from 115 to 130, and very feeble : re- 
spiration hurried ; speech indistinct and faltering. After twelve hours, 
there is~usually some reaction, with insomnia and delirium ; the eye 
assumes a peculiar brightness, and the pupil is dilated. The pulse is 
hard and full, or weak, fluttering, and intermittent ; the tongue dry, 
parched, of a yellowish colour, red in the centre and at the edges, and 
becomes brown and cracked ; the lips, teeth, and nostrils coated with 
dry sordes : there is intense thirst, and constant nausea, with occasional 
vomiting of a blackish fluid ; the evacuations from the bowels dark and 
offensive, and occasionally mixed with grumous blood ; and haemorrhage 
sometimes takes place from the nose. On the second or third day, but 
sometimes much later, and sometimes as early as the first day, the 
characteristic external marks of the disease begin to show themselves. 
Darting pains in the axillae, groins, or neck, indicate the commence- 



PLAGUE. 329 

nient of the glandular swellings and carbuncles. In favourable rases, 
these swellings are bright red: in more dangerous ones, livid or purple. 

In favourable cases, the crisis is by profuse perspiration and suppu- 
ration of the tumours, the patient beginning to mend from the sixth or 
eighth to the fourteenth or twentieth day. In unfavourable cases, the 
skin remains harsh and dry ; the pulse is small and fluttering ; low 
muttering delirium and laborious breathing set in ; the eye is sunk, the 
countenance wears a ghastly expression ; the skin becomes covered with 
petechiae and vibices ; the buboes remain stationary ; the powers of lire 
give way, the patient becomes comatose, and death takes place, com- 
monly on the fourth or fifth day, without a struggle. 

In the most favourable cases the patient can go about his usual 
avocations, though suffering from the swollen glands. In the worst 
cases, the patient never recovers from the first shock to the nervous 
system, but sinks within twenty-four hours, or as late as the second or 
third day, before the buboes have shown themselves. 

The plague may be said to assume four degrees of severity: 1. 
Slight fever, without delirium, or buboes; 2. Fever, delirium, and 
buboes ; 3. Fever, delirium or coma, buboes, carbuncles, and petechiae ; 
4. Congestive fever, fatal on the first, second, or third day, before the 
appearance of buboes. The fever, though usually continued, may 
assume the intermittent or remittent type. 

Causes. — Predisposing. — Poverty, filth, overcrowding, debility, 
disease, intemperance, adult age, female sex. Exciting. — Host pro- 
bably those of enteric fever. 

Laws of Infection, — Period of incubation, from a few hours to 
about twenty days. The disease is endemic in Egypt, often spreads to 
surrounding countries, and formerly prevailed in almost every part of 
Europe. An analogous disease is believed to exist in some parts of 
India. In common with other epidemics, plague attacks few persons at 
first, gradually attains its maximum intensity, and subsides as gradually. 
The rate of mortality is also greatest at the commencement of the 
epidemic, and at its first outbreak in each district. 

Moetality. — At first, nine-tenths of the cases, or more ; in the 
decline, a small proportion only. Throughout an epidemic, from one- 
third to two-thirds, or even four -fifths, of the persons attacked. A 
third, or nearly a half of the population of cities attacked by the plague 
is believed to have perished. h\ Smyrna, during five months of 1834, 
out of 5,727 persons attacked, 4,831 died : 1 in 23 of the whole popu- 
lation suffered, and about 1 in 27 died ; 84 per cent, of the cases 
proving fatal. 

Peogxosis. — Highly unfavourable, especially at the outbreak of the 
disease when the majority of cases end fatally : guarded even in mild 
cases. — Favourable symptoms. The early formation of firm and move- 
able buboes passing rapidly into suppuration ; profuse perspiration; an 
absence of severe fever ; life prolonged beyond eight days. — Unfavour- 
able symptoms. — Subsidence of the buboes ; suppression of urine ; haema- 



660 PESTIS. 

turia ; petechia ; obstinate vomiting ; and all the symptoms which 
would be deemed unfavourable in continued fever. The puei peral state. 

Treatment. — That of typhus fever, with warm poultices to the 
buboes and carbuncles, to promote suppuration, followed by prompt in- 
cisions. Salivation by mercury has been recommended, and, where it 
has taken place, seems to have been beneficial. The disease appears, 
however, to be almost equally fatal under all modes of treatment. 

Prophylaxis. — Separation from patients suffering under the disease ; 
during the prevalence of the malady an unusually strict observance of 
all the laws of health. The avoidance of impure food and water. In 
the case of ships from infected places, a quarantine of twenty-one days ; 
and if having cases of plague on board, twenty-one days from the 
recovery of the last case. 



( 331 ) 



CHAPTEE V. 

Febris Hectica .... Hectic Fever, 

Febris Infantum Remittens Infantile Remittent Fever. 

Pyemia Pyogenic Fever. 

Febris Peerperales . . . Puerperal Fevers. 

Cellulitis Venenata . . Dissection-wounds. 

Farginoma Glanders. 

FEBRIS HECTICA— HECTIC FEVER. 

Definition. — A remittent fever, arising from local irritation in a 
weakened constitution. 

Symptoms. — Chills, succeeded "by flushes, terminating in a hot skin 
and frequent pulse, and these by perspiration, constitute the paroxysm 
of hectic fever. There are commonly two such paroxysms or exacerba- 
tions in the twenty-four hours. The first generally occurs about noon, 
and lasts four or rive hoars. After a shoit interval of freedom, a more 
violent exacerbation follows, which increases in violence till about two 
o'clock in the morning, when a perspiration, at first partial and then 
general, breaks out and resolves the paroxysm. 

The pulse during the paroxysms is quick and frequent, ranging from 
96 to 130, or more ; the urine is high-coloured, and deposits a pink 
sediment ; the cheeks wear a circumscribed crimson blush — the hectic 
flush ; there is burning heat in the palms of the hands and soles of the 
feet. During the remission, the pulse is reduced in number, but seldom 
falls so low as in health. The appetite is not much impaired ; and the 
tongue is clean, moist, and red. The patient rapidly loses flesh. 

At length the paroxysms become more violent and the remissions 
shorter ; the appetite fails ; colliquative sweats alternate with diarrhoea ; 
and under an increased severity of these symptoms, and of the disease 
which causes the hectic fever, the patient sinks. 

Diagnosis. — From idiopathic remittent fever by the pre-existence of 
local disease. 

Prognosis. — Favourable or unfavourable according to the nature of 
the local disease, of which the fever is the effect and symptom. 

Causes. — This fever generally arises from the formation of pus, as 
in suppuration of the lungs, liver, hip-joint, &c. But it may arise from 
any local irritation in weakened constitutions, even when no suppuration 
exists. The infantile fever which arises from irritation of the alimen- 



332 INFANTILE REMITTENT FEVER. 

taiy canal is but one form of hectic. It is in advanced stages of con- 
sumption and in extensive suppurative disease of joints that hectic fever 
is developed in its most characteristic form. 

Treatment. — This must depend on the disease of which the hectic 
fever is symptomatic. When there is no apparent disease to produce 
the hectic symptoms, the treatment must be that of debility, and the 
sulphate of quina will be the appropriate 1 emeiy. 



FEBR1S INFANTUM REMITTENS— INFANTILE 
REMITTENT FEVER. 

Synonyms. — Infantile gastric remittent — infantile hectic — worm 
fever — mesenteric fever — stomach fever — low fever of children — ma- 
rasmus. 

Definition. — A non-specific fever due to gastro-intestinal irritation, 
resulting from retention of fasces, or vitiated condition of the bile or other 
digestive secretions. 

Symptoms. — Pallor, languor, drowsiness, and chilliness in the morn- 
ing ; flushed cheek, hot skin, restlessness, and feverishness towards 
evening, followed at night by profuse sweating, and towards morning 
by a disinct remission. Skin dry ; tongue moist, but coated ; pulse 
frequent ; appetite variable and capricious, or altogether wanting ; urine 
scanty ; bowels costive or relaxed, or both alternately ; the evacuations 
slimy and sour-smelling, or highly offensive, dark, green, pitchy, or clay- 
coloured, or with an abundant secretion of bile ; the abdomen tumid and 
often hot to the touch; the breath offensive ; the skin ext:emely irrit- 
able, so that the child is constantly picking the nose, lips, corners of the 
eyes, fingers, and anus. 

In less severe cases, the remittent character of the fever is less strongly 
marked ; the chilliness and languor of the morning, and the febrile exa- 
cerbation of the evening, being very indistinct, and the child merely 
looking pale and listless, and losing appetite. The disease becomes 
chronic ; symptoms of phthisis, tabes mesenterica, hydrocephalus, or 
enteric fever, now declare the presence of these diseases. The patient 
wastes rapidly, until the plump and rosy features of the child are changed 
to the meagre aspect of shrivelled old age. The more the child wastes 
away, the more restless and irritable does it become, till the last stage 
of debility arrives, when it dies from exhaustion, in a sta'e of total un- 
consciousness, or with the mental faculties unimpaired to the last. The 
disease may occur at any age. 

Morbid Appearances. — Those of enteric fever. Enlargement, 
induration, or suppuration of the mesenteric glands. The results of in- 
flammation in the brain or lungs. 

Cause and Diagnosis. — Rose-coloured spots, a fissured tongue, 
loose ochre-coloured stools, or haemorrhage, declare the presence of en- 









INFANTILE REMITTENT FEVEE. 333 

teric fever. Coma, strabismus, and convulsions ; distension in the veins 
of the scalp, and prominence of the fontanelle ; and heat of the head, 
indicate the existence of hydrocephalus or tubercular meningitis. En- 
largement and hardening of the abdomen declare tubercular peritonitis 
or tabes mesenterica. Hurried respiration and diarrhcea should excite 
suspicion of pulmonary and abdominal phthisis. 

Prognosis. — Favourable. When due to constipation or other simple 
derangement of the alimentary canal ; or to a mild form of enteric fever. 
— Unfavourable. When the other diseases above specified are declared. 

Causes. — Predisposing. — All causes of debility, such as bad air, 
want of exercise, confinement within doors, and improper or deficient 
food. — Exciting. — Irritation of the mucous membrane of the intestinal 
canal by constipation or improper diet ; worms (the symptoms in this 
case are generally less strongly marked) ; diarrhoea ; teething. 

Treatment. — Having removed all cause of irritation from the 
stomach and bowels by means of castor oil or syrup of senna, the patient 
should be placed upon restricted diet. 

As long as vomiting or diarrhcea is present, milk, milk-gruel, arrow- 
root, or broth should be prescribed. In the absence of diarrhcea, rice- 
milk, bread-pudding, and jellies may be given in addition. No animal 
food should be allowed. In infants a still stricter diet is often necessary, 
and the quantity as well as the quality of the food must be carefully 
regulated. The stomach is often very irritable, and rejects even the 
simplest farinaceous food. In such cases a table-spoonful of new milk 
from the cow should be given every half hoar or hour. If acidity be 
present, a little lime-water, or carbonate of soda, may be combined with 
it. This treatment is often very effectual. The stomach wants rest, 
and the patient wastes because it is not allowed to rest ; it rejects food 
in ordinary quantity, and will bear none in any quantity but that which 
is natural to it at that early age. 

Having adopted these general measures, attention must now be di- 
rected to the cause of the disease. The alvine secretions should be care- 
fully examined for scybala, for defective secretion of bile, for worms, 
and for mucus, each of which will point to the source of irritation. 

The dislodgement of scybala must be carefully effected by means of 
castor oil and demulcent enemata. 

If the secretions are defective, a cholagogue aperient (Form. 284) 
should be given every, or every other night ; or a mercurial alterative 
(Form. 333) morning and evening. If worms are found to be the cause 
of the irritation, an anthelmintic (Form. 314 et seq.), according to the 
requirements of the case, should be given. 

Diarrhoea and the discharge of mucus (enteritis, colitis), and other 
distinct affections of the abdominal viscera, require the tieatment appro- 
priate to these diseases. 



( 334 ) 

PYEMIA. 

Synonyms. — Simple pyogenic fever (Jenner). Septicaemia (Vogel). 
Ichorsernia (Virchow). Purulent diathesis (Tessier). Suppurative 
phlebitis. 

Definition. — Severe pyrexia, the result of an altered condition of 
the blood from admixture with pus or sanious fluid. 

Symptoms. — These come on after parturition ; wounds or blows, 
especially of bones ; any local inflammation or ulceration ; the infec- 
tious fevers, &c. They are initiated by severe rigors, followed by in- 
tense fever; pulse 100 to 140, full and hard; tongue dry and brown; 
severe muscular and articular pains ; more or less delirium. If the foot 
have been the seat of operation or injury, deep-seated pain, followed by 
swelling and tenderness in the muscles of the calf, in the ankle, knee or 
hip-joints, or in all these parts in succession. There is usually more or 
less tenderness and swelling in the course of the main veins of the limb, 
and deep-seated fluctuations may be detected in the neighbouring muscles 
of the leg and thigh. The fever may now subside, leaving the patient 
very weak, and liable to hectic : or, as is more usual, the patient sinks 
into the typhous condition, and dies comatose. If the purulent infection 
spread from the head, severe symptoms of meningitis, encephalitis, and 
pleuro-pneumonia generally appear at an early stage ; if from the upper 
extremity, pain and swelling of the muscles of the fore or upper arm, 
of the elbow, shoulder and sterno-clavicular joints, accompanied by phleg- 
monous inflammation, of the corresponding parts of the integument, and 
followed by deep-seated fluctuation. 

Sometimes the disease is still more general, and all the large joints 
of the body become painful, tense, and fluctuating, at a time when the 
lungs are partially consolidated by inflammatory exsudation. In more 
fortunate cases the disease may be limited to a hand or a foot, where 
successive abscesses make their appearance. 

Pathology. — If the exciting cause be in the lower extremity, diffuse 
abscesses form in the cellular tissue between the muscles, or in the 
muscles themselves. Inflammatory swelling and hardening of the areolar 
tissue around the coats of the main veins leading from the seat of injury, 
thickening of the coats of the veins themselves — in a word, symptoms 
of phlebitis. The affected veins are either obstructed with dark, firm 
coagula, or are filled with pus. The following is an example : — A patient 
had a bit of necrosed bone removed from the fifth metatarsal bone of the 
left foot, and two days afterwards symptoms of pysemia appeared. He 
died on the twenty-first day ; meanwhile the little wound made by the 
operation healed completely ; the left iliac vein, and the left femor?" 
vein, down to the ham, were filled with creamy pus, and the mouth, 
of their tributaries were plugged with dark, clotted blood ; the muscle r 
of the calf were imbedded in a diffuse abscess. 

If the intestines be the seat of lesion, inflammation, and numerous 
minute abscesses may be found in the liver. If the disease have sprung 



PYEMIA. 335 

from necrosis of the bones of the internal ear, or from contusion of the 
bones of the cranium, we shall find the reins of the diploe full of pus; 
pus and other products of inflammation will be effused between the dura 
mater and the bone, between or beneath the membranes in the brain 
substance itself, and very commonly in the lungs. Purulent effusions 
are commonly found in the pleural and peritoneal sacs. 

Cause. — 1. The generation of pus within the circulatory system. 
2. The absorption of pus or sanies from any suppurating surface. Since 
ulcers occasionally affect the inner surface of the heart and arteries, it 
follows that pus may be thus directly discharged from them into the 
blood. Whether the blood itself, in the absence of any external exciting 
cause, be liable to suppuration, has not been proved ; but, on the other 
hand, we have no proof that it possesses any immunity from spontaneous 
purulent degeneration. The evidence of such blood disease can never 
be great, since life must necessarily terminate before any considerable 
portion of the blood could be thus affected. 

With regard to the absorption of pus, this may take place directly, 
the pus being derived either from the inflamed inner surface of the 
divided vein, whose open extremity communicates with the suppurating 
surface, or, in the absence of inflammation, by the capillary action of the 
empty portion of that vein. In the former case the pus is the result 
of inflammation of the vein, which, from contiguity, participates in 
the general inflammation of the part. Such is the simple and obvious 
cause of pyaemia. This cause, and even the fact of pus in the blood 
itself, has been denied. But pus in the iliac and femoral veins, caused 
by a wound in the toe, as in the case just cited, is the completest proof 
possible of the existence of morphological pyaemia. 

White blood cells and pus corpuscles resemble each other too closely 
to be easily distinguished ; hence, when white cells are found in abnormal 
quantity in the blood, our only means of diagnosis are the conditions 
which have preceded their formation. If the patient have died of 
anaemia, associated or not with some non-inflammatory disease of the 
spleen or lymphatic glands, we attribute the formation of an unusual 
number of white cells to leucaemia ; if pyogenic fever have been present, 
to pyaemia. 

Prognosis. — Very unfavourable when the disease comes on after 
amputation or infectious fever ; favourable in proportion as the fever 
diminishes, the internal organs escape, and the disease localises itself in 
the limbs, or muscles and integument of the trunk. 

Treatment. — General. — That recommpnded for the later stage of 
, typhus fever; we must produce sleep and alleviation of pain by large 
doses of opium. Quinine with acid may be given in large doses in the 
early stage. Local. — Leeches and cold atfusions to the head if neces- 
sary ; hot fomentations and poultices to inflamed places ; free incisions 
wherever fluctuation can be detected. 



( 336 ) 



FEBRES PUERPERALES— PUERPERAL FEVERS. 

Under this designation authors have described several forms of disease, 
differing in many of their characters, but agreeing in the general fea- 
ture of combining a well-marked febrile affection with a local disease 
varying in seat, character, and intensity. The following distinct forms 
are recognised : — 

1. Acute puerperal peritonitis. 

2. Adynamic, or Malignant puerperal fever. 

3. Puerperal intestinal irritation. 

4. False puerperal peritonitis. 

5. Milk fever. 

general remarks on puerperal fever. 

The diseases usually characterised as Puerperal Fever, are the first 
two of this group — acute puerperal peritonitis, and adynamic or malig- 
nant puerperal fever. Both these have been observed in different 
epidemics; and cases of both forms occur in the same epidemic. These 
two forms, and all their varieties, have their origin in the same cause, 
and that cause is uterine phlebitis, the result most probably of the pas- 
sage of sanious or purulent fluid from the uterine cavity into the 
uterine circulation. If the uterus remain large and tender, and the dis- 
charges offensive, we may apprehend the accession of pueiperal fever in 
some form or other. The local lesions of puerperal fever involve one or 
all of the organs of gestation. Most commonly the disease spreads from 
the peritoneal covering of the uterus. In other cases, its muscular 
w^alis are the seat of abscess, softening, and gangrene. In others, the 
lining membrane is softened and gangrenous, and the open mouths of 
the veins exsude putrid sanies. The veins and lymphatics are inflamed, 
and either blocked up with clots or distended with pus. Diffuse pelvic 
cellulitis, resulting in lai ge purulent collections, is not uncommon. In- 
flammation and suppuration of the ovaiies are among the local lesions. 
Purulent deposits in the muscles, joints, and phlegmasia dolens, arise as 
secondary affections. 

There can be no doubt that some local lesion, sometimes not very 
severe, will be found on careful examination in every case of fatal puer- 
peral fever, and to this it is reasonable to attribute the fever. But 
some observers hold a different opinion, viz., that there is a specific 
poison which generates the fever, and that the local lesions are its 
secondary results. Puerperal fever is indeed highly contagious, and re- 
peated experience has proved that a practitioner may, after the strictest 
precautions, carry the disease from patient to patient in uninterrupted 
succession. The expeiience of lying-in hospitals is also corroborative of 
the highly contag'ous, if not infectious nature of pueiperal fever. At 
first sight, therefore, we may conclude that there is a specific poison : 
but further experience dissuades fi om this view, for it has been observed 



ACUTE PUERPERAL PERITONITIS. 337 

that the common post-mortem poison and erysipelas will in like manner 
produce puerperal fever. The true explanation appears to be this : that 
just as diastase will bring about an immediate conversion of starch into 
sugar, so will a paiticular condition of the animal fluids induce a sup- 
purative change in the tissues. While this theory will serve to account 
for the production of puerperal fever, it will be useful in indicating the 
precautions which medical practitioners should use in attending partu- 
rient women. They must avoid contact with erysipelas, post-mortem 
fluids, and putrid discharges of all kinds ; and if they have been obliged 
to handle them, the hands should be washed several times in a running 
stream, and several times soaked in a solution of kreasote or carbolic acid. 

1. ACUTE PUERPERAL PERITONITIS. 

Symptoms. — Severe rigor, commencing from the second to the fourth 
day after delivery, and in some cases much later ; followed by acute 
pain in the abdomen, and generally in the hypogastric region : the 
uterus is enlarged, and very tender. The pain is constant, augmented 
at intervals, increased by pressure and motion, and accompanied by 
fulness and tension of the abdomen. The secretions, especially the milk 
and lochia, are checked, and if the latter continue it is very offensive ; 
the skin is hot ; the pulse either frequent, small, and wiry, or full and 
bounding; the tongue furred. There is headache, restlessness, and sleep- 
lessness, with pinched, anxious, and suffused countenance, occasional 
vomiting, and hurried respiration. In unfavourable cases, the pain and 
tension of the abdomen increase, and it feels hard and tympanitic ; the 
pulse becomes more and more rapid, the skin cold and clammy, the 
head first feels confused, and then muttering delirium follows; the 
tongue becomes dry and brown, the teeth covered with sordes; distress- 
ing eructation and vomiting, hiccough, subsultus tendinum, fades hip- 
pocratica, and cold extremities, usher in the fatal result. 

Morbid Appearances. — Redness of the peritoneum, especially of 
that covering the uterus and its appendages, with more or less effusion 
of solid lymph and serum into its cavity. The uterus, ovaries, and 
Fallopian tubes covered with a creamy matter. Purulent deposits 
sometimes found in the muscular structure of the uterus ; ovaries often 
disorganised by abscess. 

Causes. — Contagion. The common causes of inflammation. It is 
often epidemic, and coexists with or precedes the malignant variety. 

Prognosis. — Favourable, but guarded, if the treatment be com- 
menced early, and if the reigning epidemic be of a mild character. 

Treatment. — General. Leeches to the abdomen in number accord- 
ing to the severity of the symptoms and the strength of the patient ; hot 
fomentations ; calomel in doses of half a grain, in combination with half 
a grain of opium, or with five grains of Dover's powder, every two, 
three, or four hours, continued till the constitutional effects of mercury 



338 ADYNAMIC, OK MALIGNANT PUERPERAL FEVER. 

are produced. Cooling drinks and cool air. Nourishing food and stimu- 
lants, as wine, brandy, and ammonia, or turpentine, taken by the mouth, 
and in the form of injection. 

Local. — The uterine cavity should be thoroughly washed out with 
warm water containing ^ part of an aqueous solution of carbolic acid 
or kreasote. A purgative of castor-oil, or salts and senna, to be ad- 
ministered at the outset, and if swelling, tension, and tenderness of the 
abdomen continue after the antiphlogistic remedies have been carried to 
their full extent, turpentine stupes or a blister may be applied to the 
abdomen. 



2. ADYNAMIC, OR MALIGNANT PUERPERAL FEVER. 

Synonym. — Puerperal hysteritis or metritis. 

Symptoms. — More obscure than the foregoing : the rigor less strongly 
marked, the pain in the abdomen less severe, little increased by pressure, 
deep-seated, more circumscribed, and often limited to the hypogastric or 
iliac regions. The pulse, from the first, extremely small, rapid, and 
weak, ranging from 130 to 160 ; countenance anxious and sunk, skin of 
a livid yellow tinge ; extreme restlessness ; intellect, though sometimes 
clear to the last, generally wandering ; low, muttering delirium ; tongue 
at first white, then duty yellow, then dry and brown ; if blood be taken, 
its colour is dark, and the coagulum very loose; eructation, vomiting, 
hiccup, diarrhoea ; the evacuations highly offensive ; lochial discharges 
foetid and often suppressed ; breasts flaccid ; abdomen tumid and tym- 
panitic; uterus large, uncontracted, tender. Death after the usual 
typhous symptoms, or slow recovery. 

Morbid Appearances. — Peritoneum of a dusky colour, the effused 
fluid dirty brown, often bloody and mixed with shreds of lymph. Foetid 
gas in the intestines. Uterus disorganised, softened, or gangrenous; 
ovaries reduced to a pulp. Pus in the veins of the uterus, and in the 
joints ; inflammation, and abscess of the cellular membrane of the leg, 
&c. In a word, evidences of pyaernia. 

Causes. — Uterine phlebitis. Contagion. 

Prognosis. — Unfavourable in all cases. 

Treatment. — The general and local treatment will be that recom- 
mended for the peritoneal variety of the disease. 

The source of the mischief lies in the uterus, and we must attack it 
there by repeatedly washing out the offensive discharge by warm disin- 
fecting fluids. The condition of the nterus should be carefully regarded 
for the first few days after delivery, and if it remain large and tender, 
and the discharges become offensive, we should lose no time in clearing 
out the disorganized clots which give rise to the foetid discharge, and 
the absorption of which is poisoning the blood. Warm water may be 
injected from time to time into the rectum. 



PUERPERAL PERITONEAL IRRITATION — MILK FEVER. 339 

3. PUERPERAL INTESTINAL IRRITATION. 

Symptoms. — General uneasiness, coming on at any period after de- 
livery, if the bowels have been neglected ; loss of appetite ; tongue furred ; 
chills alternating with flushes ; headache ; frequent pulse ; abdomen 
large and rather tense ; slight, deep-seated pain, relieved by steady pres- 
sure; nausea and vomiting of a dark and offensive fluid; diarrhoea; 
evacuations dark, foetid, watery, or slimy ; flatulence ; foetor of breath. 
In unfavourable cases there is extreme debility and despondency ; the 
red tongue of acute gastric irritation ; and often an aphthous condition 
of the tongue and mouth. The diarrhoea continuing and the strength 
diminishing, the febrile symptoms become more constant and severe, and 
the patient passes into the typhous state. 

Morbid Appearances. — Generally none. Sometimes inflammation, 
with or without ulceration, of the mucous membrane of the intestines. 

Prognosis. — More favourable than either of the preceding varieties. 

Treatment. — At first a full dose of calomel and opium, in order to 
relieve the intestines of retained or offensive matters. If diarrhoea con- 
tinue, it should be kept in check by means of sulphuric acid, bismuth, 
or copper (Forms. 85, 151, 173). If need be, the calomel and opium 
may be repeated, or a dose of castor-oil in place of it. The local and 
dietary treatment should be that of enteric fever. 

4. PUERPERAL PERITONEAL IRRITATION. 

Symptoms. — After a slight rigor, pain and tenderness of the abdo- 
men, a slightly-coated tongue, a rapid and very compressible pulse ; 
temperature of the skin little increased. It is most apt to occur in 
delicate and nervous females, after unusually severe after-pains, or from 
the violent operation of a purgative. Profuse perspiration and diarrhoea 
are present in some cases. 

Prognosis. — Favourabl e. 

Diagnosis. — From true puerperal peritonitis by the milder character 
of the symptoms. 

Treatment. — Fomentations, poultices, diaphoretics, and opiates, with 
an occasional mild laxative. Ten grains of Dover's powder, or from 
20 to 30 drops of laudanum, may be given at once, and repeated at 
certain intervals if necessary. 

5. MILK FEVER. 

Symptoms. — About the third day after delivery a well-marked rigor, 
followed by a hot and then a sweating stage ; great pain and throbbing 
in the head ; intolerance of light and sound ; flushed countenance ; con- 
tracted pupils ; conjunctiva injected ; pulse frequent, full, and hard ; 
skin hot and dry ; thirst excessive ; tongue dry and coated ; breasts hot, 
tense, and painful. If speedy relief be not obtained, the head symptoms 
become more severe, and may be attended by slight delirium ; the breasts 



340 CELLULITIS VENENATA — DISSECTION WOUNDS. 

become hard and more painful, and the operation of suckling cannot be 
borne, and, after an increase of the ger.eral pyrexia, local inflammation 
sets in, followed by abscess of the breasts. 

Causes. — Accumulation and retention of the lacteal secretion from 
want of early suckling, hyperemia, &c. 

Diagnosis. — From other puerperal fevers by the local affection. 

Treatment. — Free saline purgation, by which the tension of the 
breast will be much relieved. The breasts should be kept cool by means 
of an evaporating lotion, or they maybe gently rubbed with linimentum 
belladonna?. The infant or a breast-pump should be applied to the 
nipples as soon as they can be borne. If we fail to subdue the conges- 
tion of the breast, we should apply a few leeches and use the ordinary 
means for preventing a mammary abscess. 



CELLULITIS VENENATA— DISSECTION WOUNDS. 

Definition. — Inflammation of the cellular tissue, accompanied by 
severe febrile symptoms, produced by a poison contained in certain dead 
bodies, and absorbed from wounds. 

The wound may be received in dissecting, or may exist previously ; 
but in some cases there has been no wound or injury of any kind. 

Symptoms. — In most cases the disease sets in, within a few hours of 
the accident, with inflammation at the seat of the puncture ; but in rare 
instances the local affection is preceded by febrile symptoms, ushered in 
by severe rigors. The inflammation commencing in the puncture first 
affects the hand, then gradually extends up the arm till it reaches the 
axilla, whence it sometimes extends to the trunk, and even to the lower 
extremity. It is accompanied by swelling, tension, and throbbing pain 
in the parts affectel ; the course of the absoibent vessels is often indi- 
cated by dusky red lines, or by an erythematous blush, with irregularly 
defined outline, and the absorbent glands above the elbow and in the 
axilla are swelled and painful. The inflamed parts are at first exquisitely 
painful, but become less sensitive as the disease advances. In favoiu able 
cases the inflammation terminates in serous effusion, which is gradi ally 
absorbed. In more severe cases suppuration of the cellular tissue, both 
superficial and deep-seated, occurs, and ab.-cesses form under the theca 
of the punctured ringer, or diffused abscess attacks the cellular mem- 
brane on the hand and arm, or even on the trunk of the body. When 
the inflammation runs very high, it sometimes terminates in extensive 
sloughs. In some of the least favourable cases the local affection is very 
slight. The punctured part becomes the seat of a small vesicle or pus- 
tule, and the inflammation at once attacks the axilla, y glands ; the neck 
and upper part of the chest are swollen, stiff, and painful ; and the in- 
flammation sometimes extends over the trunk till it even i caches the 
lower extremities. Occasionally deep-seated diffused abscesses form with- 
out any superficial inflammation. The febrile symptoms often assume 



FARCTNOMA. — GLANDERS— FARCY. 341 

the typhous character, with profuse fetid sweats, great debility, extreme 
depression of spirits, and high nervous excitement. The mind is gene- 
rally unaffected ; but the patient sleeps little, and is sometimes delirious 
at night. Recovery is often slow and imperfect, the hand remaining 
stiff in consequence of the slow absorption of effused fluids, the thicken- 
ing of the textures, or the injury attending on suppuration or gangrene 
of the parts. Health returns but slowly. 

Cause. — A contagious matter absorbed, in most instances, from a 
sore or wound on the hand, in persons handling animal matter in the 
first stage of decomposition. 

Diagnosis. — The diagnosis is difficult in those rare cases in which 
no punctured wound or other injury can be discovered. The acute sen- 
sibility of the inflamed parts is very characteristic. 

Prognosis. — The mortality in the more severe class of cases is about 
50 per cent. Favourable symptoms. — Localization of the inflammation 
in the cellular tissue, and, at the worst, axillary abscess. Unfavourable 
symptoms. — Extension of the inflammation beyond the axilla and general 
pyasmia. 

Treatment. — When local inflammation runs high, leeches may be 
applied to the inflamed part, followed by warm fomentations. When 
suppuration is taking- place, warm poultices or fomentations should be 
kept constantly applied. Pus when formed should be discharged by 
free and deep incisions. 

The patient's strength will generally require to be supported by stimu- 
lants, such as ammonia, and aether, with a liberal supply of wine and a 
nourishing diet. 

If there should be acute pain and great excitement, full doses of opium 
or of its preparations should be given ; such as half a drachm of tinc- 
ture of opium, or half a grain of muriate of morphia, combined with 
ammonia or aether when the symptoms assume the typhous character. 

Free action of the bowels must be secured by the occasional adminis- 
tration of aperients. 

Prophylaxis. — Wounds received in dissection, especially of bodies 
recently dead, should be immeJiately washed, and the wounded finger 
or part strongly sucked for a few minutes. On the appearance of the 
least inflammation a poultice should be resorted to. The application of 
caustic to the wound may do good if applied at once to the bottom of 
the puncture. 



FARCIXOiMA— GLANDERS— FARCY. 

Synonym. — Equinia . 

Definition. — A contagious malady, characterised by inflammation 
of the nasal mucous membrane, and by inflammatory tumours and pus- 
tules in different parts of the body, caused by contact with the horse or 



342 FARCIXOMA — GLANDERS — FARCY. 

other quadruped affected by glanders, or with persons suffering from the 
same disease. 

Varieties. — 1. Acute glanders. 2. Chronic glanders. 

1. Acute Glanders. 

Symptoms. — The disease generally sets in with pain in the head, 
back, and limbs, rigors, nausea, thirst, great prostration of strength, 
and stiffness and pain in the joints, increased by motion. These symp- 
toms are followed, after a short but variable interval, by tumours, red, 
painful, and tender, in different parts of the body, terminating in abscesses 
discharging a foetid sanies, and passing quickly into gangrene. From 
the fourth to the sixteenth day a profuse discharge of a yellow or sanious 
fluid from the nostrils sets in, accompanied by redness, heat, swelling, 
and excoriation of the nose, lips, and cheeks ; the eyes are inflamed, and 
the eyelids swollen. Pustules and black bullae appear on the face, trunk, 
limbs, and parts of generation. These local symptoms are accompanied 
by a hot skin, urgent thirst, frequent, weak, and irregular pulse, and 
feeble respiration. The tongue is covered with a dark fur ; the skin is 
bathed in a profuse and offensive perspiration ; the evacuations are slimy 
and foetid. These symptoms increase in severity, and are followed, after 
a few days, by diffused abscesses in different parts of the body, especially 
about the joints ; typhous symptoms rapidly supervene ; the nose and 
lips become gangrenous ; the discharges extremely offensive ; low mutter- 
ing delirium sets in, and death takes place by collapse. The greater 
number of patients die within a fortnight ; few survive till the third or 
fourth week. One death is reported at the end of more than two months. 

Anatomical Characters. — Besides the superficial pustules and 
tumours, congestion of the mucous membrane of the nose, fauces, air- 
passages, and alimentary canal ; congestion of the lungs ; phlebitis ; 
purulent deposits in the lungs and joints; diffused abscess in the cellular 
membrane : and bloody fluid in the serous cavities. 

Causes. — Contagion and infection. The disease originates in quad- 
rupeds from over-work, privation, or overcrowding, and is most com- 
monly communicated from the horse to the human subject. 

Diagnosis. — The peculiar discharge from the nostrils, the seat and 
character of the pustules, the history of the case, and the occupation of 
the patient, prevent this from being confounded with any other disease. 
Farcy is distinguished from glanders by the absence of the peculiar dis- 
charge from the nostrils. But the two terms, Glanders and Farcy, are 
not used with much discrimination, at least in the human subject. F arcy, 
as it occurs in the horse, is distinguished as button-farcy and bud-farcy, 
according as the tumours attack the cellular tissue in common with the 
lymphatic glands, or the lymphatic glands only. 

Prognosis. — In acute glanders highly unfavourable. The disease 
is generally and speedily fatal. In chronic glanders more favourable. 
In farcy still more favourable. 



FABCmOMA. 343 

Treatment. — Xo remedy has yet been discovered. The treatment 
must be that of typhus fever. The treatment of the local inflammation 
the same as in cases of dissection wound. 

Prophylaxis. — Those who are employed in grooming horses affected 
by glanders should wear gloves, avoid contact with the diseased animal, 
and practise scrupulous cleanliness. Wounds or sores in grooms should, 
like dissection wounds, be promptly treated by suction. Stables in which 
glandered horses have been kept should be thoroughly cleaned and fumi- 
gated, scraped and whitewashed, and harness and horsecloths either de- 
stroyed or exposed to a high temperature, and thoroughly washed. Carbolic 
acid should be freely employed. 

2. Chronic Glanders. — In this form of the disease the local symp- 
toms precede the febrile excitement, and the course of the malady more 
nearly resembles the effects of a dissection wound. After a few hours 
from the introduction of the poison, the lymphatics of the wounded part 
become inflamed, and the innammation extends along the fore-arm and 
arm to the axilla. The parotid and submaxillary glands may also be 
swollen and inflamed. Extensive abscesses form in the cellular tissue 
of the limb, and, in fatal cases, the pustular eruption, accompanied by 
dark bullae, appears on the skin, followed by well-marked hectic fever. 
The duration of the fever is often very considerable, both in favourable 
and in fatal cases. 

The term chrome glanders is used as synonymous with acute farcy ; 
chronic farcy being a still milder and more protracted disease. 



( 344 ) 



CHAPTEE VI. 

Scrofula King's Evil. 

Rachitis Rickets. 

Mollities Ossium . . . Softening of the bones. 

Purpura Scurvy. 

Rheumatismus .... Rheumatism. 

Podagra Gout. 

SCROFULA or STRUMA— KING'S EVIL. 

Definition. — The deposit of tubercle in several organs of the body, 
and a tendency to indolent inflammatory swellings and chronic ulcers. 

The most common forms of scrofulous disease are, chronic inflamma- 
tion and suppuration of the glands of the neck, strumous ophthalmia, 
and chronic ulcers of the cornea, indolent abscesses of the skin, enlarged 
tonsils, mollities ossium, diseases of the bones and joints, psoas abscess, 
tabes mesenteric^, and pulmonary consumption. The scrofulous, too, 
are more subject than others to hysteria and to mental disorders. 

The form of scrofula to be described in this place is that which attacks 
the absorbent glands of the neck. Other scrofulous affections will be 
considered in these pages under Rachitis, Tabes Mesenterica, Phthisis 
Pulmonalis, and Strumous Ophthalmia. 

Symptoms. — The scrofulous constitution is indicated by a lax habit 
of body, a thin fair skin, delicate rosy complexion, fair and fine hair, 
full upper lip, and tumid septum and alas nasi. It is also apt to attack 
spare, pale children, with projecting foreheads, misshapen heads, narrow 
and deformed chests, swollen fingers, enlarged joints, irregular and 
unsound teeth, and tumid abdomens. In addition to these marks of the 
scrofulous diathesis, maybe mentioned a languid circulation, a slow and 
weak pulse, cold extremities, and great liability to chilblains. A weak 
digestion, variable appetite, and torpid, or disordered, bowels are also of 
frequent occurrence in scrofulous children. The subjects of this disease 
often display great acuteness and aptitude, with lively imaginations, and 
ardent affections, and not unfrequently a great precocity of intellect. 

The scrofulous affection of the glands of the neck first appears as 
a slight swelling of one or more of the glands of one or both sides, 
especially of those situate beneath the lower jaw. The tumour is even 
to the touch, moveable, not tender, nor marked by any inflammation 
of the skin. Sometimes the swollen gland or glands will remain in 
this state without perceptible change for weeks, months, or even years ; 



SCROFULA. 345 

sometimes they undergo a very gradual enlargement ; sometimes they 
coalesce, so as to form irregular knotty swellings; sometimes they gra- 
dually disappear. In a large proportion of cases they proceed to suppu- 
ration. Fluctuation is perceived, the tumour points, the skin gives way, 
and pus, followed by a sero-purulent, mixed with a curdy or cheesy 
matter, is discharged by or.e or more openings. The absce-s thus formed 
heals slowly, has an unhealthy appearance, a dull-red colour, with hard, 
swollen, irregular edges, and an uneven base, clogged with curdy matter. 
After the ulcer has healed, an irregular and unsightly scar occupies its 
site. Though the superficial glands of the neck are those most fi equently 
attacked, those deeper- seated are often implicated; and the disease some- 
times spreads along the course of the absorbents from one gland to 
another. 

The constitutional disturbance which accompanies these local changes 
is usually slight. The patient retains his colour, does not lose flesh, and 
has every appearance of good health. When the local disease, however, 
is very extensive, and the glands suppurate, hectic fever sets in, with 
great debility and emaciation. In advanced stages of the disease, espe- 
cially in young adults, pulmonary consumption may supervene ; and 
the two diseases then run on together until they destroy the patient. 

Causes. — Predisposing. Hereditary taint; syphilis or gout, or a 
shattered constitution in one or other of the parents; disparity of age in 
the parents, or too near relationship ; childhood, youth, and the early adult 
age. The disease is of most common occurrence between the third and 
seventh year ; it is comparatively rare after puberty, but may occur as 
late as thirty years of age. — Exciting. All causes of debility acting on 
the predisposed— such as sedentary habits of life ; scanty and unwhole- 
some food ; the impure air of crowded and ill -ventilated nurseries, schools, 
workshops, and factories, and the confined rooms inhabited by the poorer 
classes; overwork; damp and low situations ; exhausting maladies, espe- 
cially fever, and the febrile exanthemata. The immediate exciting cause 
is often an attack of catarrh. The disease is common among prisoners. 

Diagnosis. — From simple glandular inflammation, by the indolent 
character of the swellings. 

Prognosis. — The disease, when limited to the absorbent glands, is 
rarely fatal, but tabes mesenterica. white swelling of the joints, disease 
of the spine, and pulmonary consumption, are dangerous and fatal mala- 
dies. Scrofula is always slow T and tedious in its course, and very uncertain 
in its duration. 

Morbid Anatomy. — The glands contain a soft curdy matter. The 
other viscera, especially the mesenteric glands and the lungs, contain 
tubercular deposits. Scrofulous disease of the joints and bones is also of 
common occurrence. 

Treatment. — A nutritious diet, adapted to the age of the patient, 
with a due allowance of animal food. Wine and malt liquors in mode- 
rate quantity may be given with advantage. In scrofulous infants 
brought up by hand, the substitution of the mother's milk, or of pure 



346 RICKETS. 

milk from the ass or cow. Daily exercise, short of fatigue. Warm 
clothing (flannel next the skin, avoiding over-clothing). 

Change of air, especially from a low, damp situation to a high, dry, 
and bracing air. Sea- air and sea-bathing in the summer and autumn. 

A cold or tepid bath daily, followed by friction with a rough towel, 
or the shower-bath once or twice a week ; and gentle aperients adminis- 
tered at short intervals. A few grains of rhubarb, with small doses of 
hyd. c. creta may be given occasionally, followed by a tea or dessert-spoon- 
ful of castor-oil the following morning. 

Chalybeate tonics, especially the tinctura ferri perchloridi, the am- 
monio-citrate, and the dried sulphate, or quinine and iron in combination, 
are suitable preparations. 

Iodide of iron in doses of from one to five grains, three or four times 
a day, and cod-liver oil (a tea-spoonful three times a day, gradually in- 
creased to a table-spoonful; are valuable remedies in scrofula. 

II. Simple enlargement of the glands of the neck may be treated by 
the constant application of the emplastrum ammoniaci c. hydrargyro, or 
they may be painted frequently with iodine paint. If the patient be at 
the sea-side, poultices of sea-weed (the Fucus vesiculosus) may be kept 
constantly applied. When suppuration takes place, it must be encou- 
raged by poultices, and the matter be let out by a small vertical or 
oblique incision. Caustic should never be used for this purpose, as it 
causes unsightly scars. 

Open scrofulous ulcers generally put on an indolent character, and 
must be treated by local stimulants, and in extreme cases by caustics. 
In the treatment of other local affections occurring in scrofulous habits 
this peculiarly indolent character must be borne in mind. 

Remedies. — Mercurial preparations given as alteratives, such as 
Plummer's pill, or the perchloride of mercury (Form. 321). Alkalies 
and alkaline earths, of which the best is the liquor potassaB, in doses of 
from five to twenty drops, three times a-day in some tonic infusion ; or 
lime-water in doses of from one to two drachms. The mineral acids, 
especially the nitro-muriatic acid. The chlorides of Barium and of 
Calcium. (Liquor barii chloridi, Tr\iii to TY^v, cautiously increased; 
or Liquor calcii chloridi, TT^xxx to TY\xl, gradually increased.) Extract 
of Conium. 

From the slow progress and uncertain march of scrofulous affections, 
many remedies seem serviceable which are really inert. In this respect 
scrofula resembles pulmonary consumption. The most opposite remedies 
are confidently recommended and deemed efficacious. 



RACHITIS— RICKETS. 

Definition. — A distortion of the bones, occurring in infancy and 
childhood, from deficiency of earthy matters. 

Symptoms. — The disease sometimes begins soon after birth ; more 
frequently when the child is five or six months old ; more frequently 



EICKETS. 347 

still before the close of the second year. After this time it is very rare. 
When the disease first sets in, the child is observed to be less healthy 
and strong than children of the same age. The face is pale, and the 
body emaciated. Teething begins late, and goes on slowly, and the 
teeth soon become loose and carious. The fbntanelles and sutures are 
usually open, the head, though smaller than usual, is generally large in 
proportion to the face, and the forehead prominent ; the chest is flat- 
tened at the sides, and the sternum projecting, the epiphyses of the long 
bones become spongy, and the joints swell. This enlargement is com- 
monly first perceived in the wrists and ankles. As the disease advances, 
the long bones yield to the weight of the body, and are twisted by the 
action of the muscles ; the spine is curved and bent ; and the pelvis dis- 
torted and narrowed. If the patient has begun to walk, his gait is 
unsteady and waddling. The mental faculties, except in cases of cre- 
tinism accompanied by distortion, are unimpaired, and even more acute 
than in children of the same age. 



Causes. — Predisposing. Hereditary predisposition. A peculiar 
diathesis, allied to the scrofulous, but not identical with it ; for neither 
enlargements of the cervical glands, nor tuberculous deposits in the 
lungs, are common in rickety subjects. — Exciting. Bad nursing, bad 
food, bad air, want of cleanliness. 

Pathology. — Defective nourishment, or mal-assimilation of the 
food, leading to a deficiency of earthy matter in the bones. Dr. J. 
Davy found 100 parts of the dry tibia of a rickety child to be composed 
of 74 parts of animal matter and only 26 of earthy salts. The micro- 
scopic appearance of rachitic bone is very characteristic. Ossification is 

Fig. 54. 




observed to have taken place so partially and imperfectly that the bone 
is made up of isolated and apparently independent masses of unaltered 
cartilage, and of completely and incompletely formed bone promiscuously 
distributed. Owing to the imperfect ossification of the matrix, the con- 
version of the enlarged cartilage cells into lacunae is readily seen (Fig. 54). 

Prognosis and Results. — Favourable. The disease is very rarely 
fatal. In mild cases complete recovery often takes place ; the swollen 
joints gradually returning to their natural size : in severe cases the dis- 
tortion of the body is permanent, but the bones ultimately resume their 
normal composition, and even become more dense and compact than in 
persons originally healthy. Distortion of the pelvis causing obstruction 
to parturition is the only result which endangers life. 



348 MOLLITIES OSSIUM — SOFTENING OF THE BOXES. 

Treatment. — 1. Food of good quality and adapted to the child's 
aze is of the first consideration. If the mother is delicate and cannot 
nurse, or if the milk he poor, the child should be supplied with fresh 
milk from one cow. If this be not assimilated, a wet nurse may be 
provided. Dry and pure air, cold or tepid salt-bathing, and frequent 
frictions. Tonics, especially preparations of iron, such as steel- wine or 
the sulphate or potassio-tartrate of iron. Cod-liver oil may also be pre- 
scribed with advantage. Children living in large towns should be 
removed to the countiy. The state of the bowels should be carefully 
I to. In order to supply the defective constituents phosphate of 
lime may be given in doses of from five to ten grains three times a day, 
suspended in chak mixture. Preparations of iron may be given at the 
same time. If the child be veiy weak, phosphate of ammonia, in doses 
of from five to ten grains given three or four times a day, will be bene- 
ficial ; milk and lime-water in equal parts form an appropriate drink. 

2. The distorted limbs must be supported by such mechanical con- 
trivances as do not interfere with the proper action of the muscles ; and 
care should be taken not to allow the weight of the body to rest on those 
parte which show a tendency to swell or bend. 



MOLLITIES OSSIUM— SOFTENING OF THE BONES. 
Synonyms. — Osteo-malacia. Malacosteon. Atrophy of bone. 

Definition. — Perverted nutrition of the bones resulting in rapid 
fcion of the earthy matter and consequent softening. 

Symptoms. — The symptoms of this disease are very obscure, and its 
presence is rarely recognised till it has made considerable progress. 
Severe and long-continued pains in the pelvis and lower extremities, con- 
sidered as rheumatic pains, have been present in the greater number of 
cases ; but the disease is generally recognised for the first time by a 
fracture occumng in one of the bones of the extremities by the applica- 
tion of slight force ; by the bending, twisting, or distortion of one or 
other of the limbs : or, in females, by the increasing difficulty of par- 
turition, arising from a growing distortion of the pelvis. 

Anatomical Characters. — The cancelli of the bone completely 
absorbed, and the bone reduced to a mere shell, filled with medullary 
matter. The bones so softened as to admit of being cut with a knife. 

The periosteum sound. The teeth not implicated. 

Causes. — Predisposing. The female sex. It is comparatively rare 
in men. The adult age. — Exciting. Obscure. 

Diagnosis. — From rachitis by the age of the patient ; rachitis is a 

b of infancy and childhood, mollities ossium of adult age. 

Prognosis. — Unfavourable. The disease often makes slow progress. 
Treatment. — There is no remedy or mode of treatment on which 






PURPURA — SCURVY. 349 

reliance can be placed. The treatment must, therefore, be directed to 
the improvement of the general health, by nourishing diet, tonics, and 
such other medicines as are indicated by the existing state of the system. 



PURPURA— SCURVY. 



Synonyms. — Haemorrhoea petechialis. Petechias sine febre. 

Varieties. — 1. Purpura simplex ; 2. Purpura urticans ; 3. Pur- 
pura hemorrhagica (land-scurvy) ; 4. Purpura nautica (sea-scurvy). 

1. PURPURA SIMPLEX. 

Symptoms. — After slight uneasiness, or giddiness, an eruption of 
small irregularly rounded patches, of a dark-claret colour, chiefly on the 
thighs and legs, but sometimes over the whole body. After a few days, 
the first patches begin to fade, and new ones appear. The skin readily 
bruises, and bleeding from even slight wounds is often controlled with 
difficulty. There is little disturbance of the general health. The disease 
may last from a few weeks to as many years. 

Pathology. — Capillary haemorrhage in the cutis occurring in isolated 
spots. Blood deficient in fibrine. 

Causes. — Predisposing. Peculiarity of constitution, debility. — Ex- 
citing. Febrile states of system. It is oiten attributed to cold. 

Diagnosis. — By the shape and colour of the spots, and the uninjured 
cuticle. 

Prognosis. — Favourable. 

Treatment.— A nourishing mixed diet, and proper exercise, astrin- 
gent chalybeate tonics, the mineral acids, and occasional mild aperients. 

2. PURPURA URTICANS 

Is a form of urticaria, consisting in a discoloration of the patches of 
nettle-rash by blood poured out in small quantity into the cellular 
tissue. (See Urticaria.) 

3. PURPURA HEMORRHAGICA — LAND-SCURVY. 

Symptoms. — Weakness, lassitude, and pains in the limbs, with a 
feeble pulse of variable frequency ; petechias of larger extent than in the 
first variety ; occasionally bullae filled with liquid blood ; gums swollen, 
livid, and spongy ; haemorrhage from the gums, nostrils, uterus, and 
raucous membranes generally; rigidity of the legs from effusion of 
blood into the texture of the muscles ; extensive bruises. In severe 
cases, all the symptoms of sea- scurvy. 

Pathology. — A diseased condition of the blood : with defect or 
excess of fibrine ; but in either ca^e it is deficient in power of coagulat- 



350 PURPURA — SCORBUTUS. 

ing, and forms a loose, rotten clot. The albumen is said to be so far 
changed as to require a temperature &° higher than usual for its coagu- 
lation. 

Causes. — Those of sea-scurvy. 

Sequels. — Ulceration of Peyer's patches. Shedding of the hair. 

Necrosis. 

Treatment. — A generous mixed diet, with an allowance of wine or 
beer. Astringent tonics, chalybeates and acids (Forms. 163, 168). A 
table-spoonful of lemon-juice may be given with advantage three or four 
times a day. 

Prophylaxis. — Minute inquiries should be made as to the diet of 
the inmates of prisons and workhouses. It may not be deficient in 
quantity or in the quality of the articles of which it consists, but the 
essential element of vegetables containing an acid may be absent. For 
instance, scurvy has been traced in one case to the substitution of rice, 
which does not contain such an acid, for the potato, which does contain 
it; and the restoration of the potato sufficed to banish the disease. As 
the cheapest of requisite vegetables, the potato should always form part 
of the ordinary diet of prisons, workhouses, and hospitals. 

4. PURPURA NAUTICA. SCORBUTUS — SEA-SCURVY. 

Symptoms. — Heaviness, weariness, dejection of spirits, aversion to 
exercise, dull pains in the limbs, especially during night ; anxiety and 
oppression at the praecordia ; palpitation and shortness of breath on the 
slightest exertion ; a pale, sallow, and bloated countenance ; the skin 
in some cases hot, in others cold and contracted ; the pulse in some cases 
infrequent, in others small and frequent ; the tongue clean, moist, and 
pale ; the gums swollen, spongy, and livid, bleeding upon the slightest 
touch, and at length separating from the teeth, which become loose ; 
the breath offensive ; petechias appear on various parts of the body ; the 
slightest scratch degenerates into a foul ulcer ; the slightest pressure 
produces a bruise, and old cicatrices open afresh, and discharge a thin 
sanious fluid ; spontaneous ulceration likewise takes place upon the gums 
and on the surface ; the joints become swelled and stiff; the muscles of 
the legs, and of the calf especially, rigid, contracted, and exceedingly 
painful ; the bowels are either obstinately constipated, or there is 
diarrhoea ; the urine tinged with blood, or transparent, high-coloured, 
and acid. Great emaciation ensues ; passive haemorrhages take place 
from the gums, nose, and ears, from the stomach and bowels, and occa- 
sionally from the lungs and bladder ; all the excretions become intoler- 
ably foetid ; but the appetite frequently remains good, the patient 
retains his intellectual faculties, and talks with a loud voice, but is apt 
to faint on the slightest motion. Many patients have expired as they 
were being carried from their hammocks. Sudden death has also often 
taken place in the earlier stage of the disease, during some violent effort. 



SEA-SCURVY. 351 

Causes. — Predisposing, A cold moist atmosphere ; sleeping in damp 
clothes or heds ; the winter season ; cold climates ; fatigues and hard- 
ships ; previous attacks of illness, especially of scurvy ; indolence ; de- 
pressing passions, and the general causes of debility ; scanty supplies of 
water ; deficient clothing ; want of cleanliness ; impure air. — Exciting. 
A diet restricted to a few articles of food, such as salt meat and bis- 
cuit ; a deficiency of vegetable food, and especially of vegetable acids. 

Diagnosis. — The absence of feverish symptoms, cerebral disturb- 
ance and contagion, together with its mode of access, distinguish this 
condition from fever and other diseases. Scurvy, as it formerly occurred 
on land, in besieged cities, in camps, and in monasteries, and occasionally 
among entire populations, and as it now shows itself trom time to time 
in prisons and workhouses, is essentially the same disease as that which 
occurs at sea. 

Prognosis. — Generally favourable, if the previous health and 
strength were good, and if a proper vegetable diet, or other proper sub- 
stitute, can be obtained. — Unfavourable. Where there is great pro- 
stration of strength ; extreme oppression at the praecordia ; redness of 
the eyes and flushed countenance ; a rapid weak pulse ; profuse haemor- 
rhages ; petechias of a dark-livid colour, and of great extent ; fetid and 
involuntary evacuations. 

Treatment. — Indications. I. To supply what is wanting in the 
diet. II. To palliate urgent symptoms. 

I. The first indication is fulfilled by fresh vegetables, or fruits, as the 
orange, the lime, and the lemon ; fermented and fermenting spirituous 
liquors, as ale, cider, and spruce beer, and the light French and Ger- 
man wines, sauerkraut. Where great debility is present the stronger 
spirits may be given. At sea, t ^j of lemon or lime-juice should be 
served out daily to each individual. 

Occasional aperients of infusion of tamarinds, cream of tartar, or the 
sulphates of soda and magnesia, may be given, and the utmost attention 
must be paid to cleanliness and ventilation. 

II. Ulceration of the gums require astringent gargles of alum, mu- 
riatic acid, chloride of soda or of lime, or decoction of bark ; or the 
steam of vinegar. Acute pains are relieved by opium ; oppression at 
the chest and difficulty of breathing, by diffusible stimulants, such as 
nitric, sulphuric, or chloric aether with camphor ; contraction of the 
muscles of the legs, by hot fomentations of vinegar and water, or emol- 
lient cataplasms, and by friction ; scorbutic ulcers upon the surface of 
the body by slightly-stimulant applications. 

The hcemorrhagic tendency and debility will be best combated by the 
free use of the mineral acid and chalybeate astringents. 

Prophylaxis. — A due admixture with the food of fresh or preserved 
vegetables, or where these cannot be procured, lime-juice, lemon-juice, 
or citric acid. Also the acetate and bitartrate of potash. Among fresh 
vegetables, the potato and yam are the best. As a moist atmosphere is 
undoubtedly injurious, dry rubbing should be substituted for frequent 



352 KHEUMATISMUS — RHEUMATISM. 

washing in our ships. Cleanliness and ventilation should also le rigidly 
enforced; and where men are placed in ciicumstances favourable to 
mental inaction and despondency, such employments and amusements 
as tend to counteract these states of mind. 



KHEUMATISMUS— RHEUMATISM. 
Varieties. — 1. Acute. 2. Chronic. 3. Muscular. 

1. RHEQMATISMUS ACQTUS — RHEUMATIC FEVER. 

Definition. — Acute inflammation of the larger joints, attended by 
well-marked febrile symptoms ; often shifting fiom joint to joint; and, 
in many cases, attacking the fibrous textures of the heart. 

Symptoms. — The disease generally sets in soon after exposure to cold 
and wet, with all the symptoms of a severe attack of catarrh ; the pain 
in the back and limbs being unusually severe, and accompanied by a 
sensation of coldness and stiffness. In the course of one, two, or three 
days, inflammation shows itself in one or more of the larger joints, cha- 
racterised by redness and heat of surface, acute pain, extreme tenderness, 
tumour, and tension. There is great constitutional disturbance, with 
extreme restlessness, intense thirst, and loss of appetite. The pulse 
ranges from 90 to 120 ; and is full, hard, and jerking ; the blood, drawn 
from a vein, is cupped and buffed ; the tongue is coated with a thick 
and soft white fur ; the bowels are usually obstinately costive ; the 
urine scanty and high-coloured, and a strong acid reaction, but at this 
period of the disease generally free from sediment. The skin is often 
bathed in a profuse strong sour-smelling sweat, which, however, affords 
no relief. The febrile symptoms and the pain generally suffer an exa- 
cerbation at night. 

The disease is rarely confined to the joints first affected ; but after 
some hours or days, attacks fresh ones, sometimes continuing unabated 
in those first affected, at others leaving them quite free from pain and 
swelling. In rarer instances, it returns to the joints first attacked, and 
ultimately extends to all the large joints of the body. Some amend- 
ment usually takes place in about a fortnight ; the pain lessens, espe- 
cially at night ; there is less fever and perspiration ; the urine is more 
abundant, and lets fall a copious deposit of the mixed urates ; the appe- 
tite returns; the thirst diminishes; the pulse falls ; and the patient's 
movements become more free. Convalescence, however, is rarely unin- 
terrupted, and the affection of the joints of. en assumes a chronic form. 

In a large proportion of cases, the disease extends to the fibrous tissues 
of the heart, and the younger the patient the greater the liability to 
this affection. The symptoms which denote this formidable complica- 
tion are dyspnoea, palpitation, and a sense of oppression, increased by 
pressure in the intercostal spaces, by inspiration, and by lying on the 
left side. In some cases pain in the region of the heart is superadded. 



ACUTE KHEUMATISM. 353 

The pulse is generally quickened, and has a peculiar thrill. As this 
affection is often obscure, it should be carefully sought for, and its earliest 
indications attended to. 

For the stethoscopic signs, see Pericarditis and Endocarditis. 

Sometimes, too, the disease is complicated, and recovery retarded by 
attacks of bronchitis, pneumonia, or pleurisy ; by inflammation of the 
brain and its membranes ; and by inflammation of the sclerotic coat of 
the eye, all of which diseases are due to the rheumatic poison. 

Morbid Anatomy. — Inflammation of the fibrous and synovial mem- 
branes of the parts affected, with much effusion of clear or milky serum ; 
and more rarely of deposits of lymph. In the heart, the results of Car- 
ditis and Pericarditis. 

Pathology. — Rheumatism is essentially a blood disease ; and the 
poison appears to be lactic acid. It also contains a very large excess of 
fibrine. The urine is excessively acid and high-coloured, and contains 
much uric acid. 

Causes. — Predisposing. Previous attacks. Youth. Debility. Spring 
and autumn. — Exciting. Exposure to wet and cold. 

Diagnosis. — The pathognomonic symptoms of the acute form are in- 
flammatory fever, with pains and inflammation of the larger joints, over 
which the integuments become distended, smooth, and of a peculiar 
pale-red colour. The severe muscular pains of commencing typhus may 
cause that disease to be mistaken for rheumatism. Rheumatism may 
coexist with variola (see page 310). 

From Podagra (see Podagra). From Neuralgia, by the history of 
the case ; by the presence of inflammation and fever ; and by the tact 
that, in neuralgia affecting the same parts, the pain is generally confined 
to a single joint. From syphilitic periostitis, by the extreme tenderness 
on pressure of the inflamed portion of bone in that disease ; and by its 
occurrence in the bones of the cranium, on the sternum, or on the shin- 
bone, as well as in the bones forming the large joints ; also, by the 
previous history of the case. 

Prognosis. — Favourable symptoms. A general, but not unnaturally 
profuse, perspiration ; the repeated or continuous deposit of a lateritious 
or furfuraceous sediment in the urine. — Unfavourable. Metastasis of 
the inflammation to the heart, chest, or brain. The disease is very 
rarely fatal ; but often leaves behind it organic disease of the heart by 
which life is shortened, or chronic inflammation of the joints, with a 
great susceptibility of future attack. In favourable cases, and in per- 
sons otherwise of good constitution, the duration of the disease is from 
three weeks to a month. 

Treatment. — 1. General. Since the system is saturated with acid, 
the most rational treatment is the alkaline, and it is the most successful. 
From half a drachm to two scruples of the bicarbonate of potash may 
be given, dissolved in half a pint of water, every three or four hours, 
or an ounce of lemon-juice taken with twentv grains of bicarbonate of 

2 A 



354 CHRONIC ARTICULAR RHEUMATISM. 

potash dissolved in three ounces of water. The nitrate, bitartrate, and 
acetate may also be given with advantage. £i of nitrate of potash, 
taken at intervals in half a gallon of water, is in itself an efficient 
remeJy. 

A single full bleeding, followed up directly by sulphate of quinine in 
two-grain doses every three hours, is a mole of treatment which I have 
seen adopted, and have frequently practised, with veiy decided advan- 
tage. (G.) 

The adoption of either of these methods of treatment does not pre- 
clude the use of other means in cases of unusual severity, or of a com- 
plicated character. 

The bowels must be kept in free action by means of saline purga- 
tives, such as a Seidlitz powder, or from 40 to 60 grains of compound 
jalap powder, given as often as necessary. 

For the relief of pain, x or xii grains of compound ipecacuanha powder 
may be given at bed-time. 

Warm baths may be used with advantage before the pain in the 
joints has become so severe as to create difficulty in moving the patient. 
When the disease is beginning to abate, they may also be administered 
two or three times a week. Carbonate of potash or of soda may then 
be added to the bath in sufficient quantity to render it decidedly alkaline. 

2. Local applications. — The affected joints should be enveloped in 
cotton wool. When the skin perspires prof :sely, and the surface is very 
hot, cloths dipped in an alkaline lotion (Potassae carb. gii Aquae Oi.) 
and covered with oilskin, may be substituted ; or, if the pain be very 
acute and the patient restless, lint saturated with belladonna or chloro- 
form liniment, may be laid on the part. Small blisters applied to the 
joints as they are successively affected, often give great relief. 

When the disease is complicated with heart-affection, cupping, followed 
by blisters to the region of the heart, is indicated ; or, if the patient be 
very weak, a large blister, dressed with mercurial ointment, at the same 
time that calomel and opium are given to produce slight constitutional 
effects (Form. 329), 

2. CHRONIC ARTICULAR RHEUMATISM. 

Symptoms. — The chronic form may be a consequence and termination 
of the acute, or it may be independent of it. In the first case, the joints 
are left weak, stiff, and in some instances cedematous ; and the pain, which 
was before shifting, is now usually confined to particular joints. Some- 
times, however, it still shifts from joint to joint, but is not attended by 
acute inflammation or fever. Exposure to wet and cold often brings on 
an attack, which continues for a considerable time, and at length goes off 
leaving the affected joints weak and stiff. 

Chronic articular rheumatism, when not a sequel of the acute disease, 
generally attacks the smaller joints of the hands and feet, and is then 
commonly called rheumatic gout. 

Treatment. — When the disease is confined to one or two joints, leeches 
on every marked return or increase of inflammation ; blisters at a short 






MUSCULAR AND TENDINOUS RHEUMATISM. ODD 

distance fiom the affected joint, or even to the joint itself; and friction. 
When there is much effusion about the joints, or when the disease is 
more extensive, we must employ general remedies recommended for the 
acute disease. The vapour-bath is a most powerful remedy. The warm 
bath is of less efficacy, but the thermal mineral waters of Vichy. Aix- 
la-Chapelle, Karlsbad, Wiesbaden, Buxton. &c.,have long enjoyed a high 
and deserved reputation in the treatment of chronic articular rheuma- 
tism. A warm climate also proves beneficial to cases which have arisen 
in a cold one, though warm climates are peculiarly favourable to the 
occurrence of rheumatic affections. 

Remedies. — Dover's powder in repeated small doses (gr. v three 
times a day) ; Yinumcolchici (TYlxx.) in combination with opium (Tinct. 
opii, TY1 v ; guaiacum, in the form of the mixture, or ammoniated tinc- 
ture; iodide of potassium (gr. hi to gr. v) with sarsaparilla (especially 
indicated where there is a syphilitic taint). 

3. MUSCULAR AND TENDINOUS RHEUMATISM. 

Varieties. — Some forms of the disease have distinct names, according 
to the seat of the affection ; as pleurodyne, when it attacks the muscles 
of the side ; lumbago, when the seat is in the loins ; crick in the neck. 
when it affects the neck. Kheumatism of the muscles of the back of 
the thigh is sometimes, though incorrectly, called sciatica. The pain 
is very frequently localized in a particular tendon, at its insertion into 
the bone, e. g. the insertion of the deltoid, and tendo Achillis. 

Symptoms. — Pain, varying in character and severity, from a dull 
aching to the most acute lancinating pain, affecting the entire body, the 
trunk, a single limb, or a single muscle or group of muscles ; coming 
on sometimes suddenly, at others alter shivering and slight feverish n ess : 
often forming the most distressing features of a common cold, and re- 
maining after the other symptoms have vanished. The severe pains in 
the chest and abdomen, which accompany spinal irritation, are to be 
distinguished from rheumatic pains. (See Spinal Irritation.) 

Prognosis. — Favourable. The disease is free from danger. Its dura- 
tion may vary from a few hours or days to as many months or years. 
The general health is little if at all affected. 

Diagnosis. — The pain is increased by motion of the affected parts, 
by pe.cussion with the points of the fingers, and by the sudden removal 
of pressure ; but it is relieved by firm pressure gradually applied. It 
is sometimes augmented, sometimes relieved, by the warmth of bed. 

Treatment. — This form of rheumatism is also benefited by alkalies, 
but its complete removal requires a long continuance of the treatment. 
Guaiacum, in combination with alkalies, is often efficacious. Opiate 
liniments or small blisters may be occasionally applied to the painful 
part. Ala gneto -electricity, and the hot bath, often afford much relief. 
The condition of the urine will in every case furnish useful indication as 
to treatment. If it contain excess of uric acid we must persevere with 
alkalies. 



356 PLEURODYNE. 

Prophylaxis. — Persons subject to rheumatism should wear flannel 
next the skin ; they should protect the parts most liable to the disease ; 
and avoid malt liquors and exposure to wet and cold. 

PLEURODYNE. 

Pain in the left side is present in almost all the functional diseases of 
young and middle-aged females ; in dyspepsia, amenorrhcea, menorrhagia, 
leucorrhcea, hyperlactatio, and chlorosis, and in debility, however in- 
duced. In males it is equally common on both sides. It often accom- 
panies chronic rheumatic pains of the joints or tendons. Acute pain in 
the muscles of the left side geneially precedes by some days or weeks 
the appearance of shingles. (See Herpes zoster.) 

Causes. — Predisposing. Debility. — Exciting. Over-exertion, as 
in coughing ; flatulent distension of the stomach ; the rheumatic poison. 

Diagnosis. — The diagnosis of pleurodyne is of great importance, 
though the disease itself is of little or none. It is distinguished fiom 
pleuritis, with which it is often confounded, to the great injuiy of the 
patient, by the absence of the constitutional symptoms of acute inflam- 
mation, and of the stethoscopic indications of pleurisy ; by being increased 
by motion of the affected parts, as in raising the arm, or twisting sud- 
denly round, or by a sudden inspiration or expiration ; by the effect of 
sudden and slight percussion with the points of the fingers ; and by the 
immediate increase of the pain on the removal of pressure. It is distin- 
guished from the neuralgic pain preceding the eruption of shingles by 
its less severity. 

Complications. — With chest disease (for it is a common consequence 
of a cough) ; with acute dyspepsia ; and w T ith any of the debilitating 
diseases mentioned above. 

Treatment. — If chronic, the emplastrum belladonna?, opii, or robo- 
rans should be applied to the seat of the pain ; when acute, a mustard 
poultice. Symptomatic pleurodyne must be treated by removing its 
cause. When the affection accompanies rheumatism or gout, the treat- 
ment for those diseases should be adopted. 

Allied to pleurodyne is an acute pain of the muscles of the abdomen 
or diaphragm, or of both together. That of the abdomen is apt to be 
confounded with peritonitis, as pleurodyne with pleurisy. The diagnosis 
is easy. Graduated pressure gives relief, except when a sudden expira- 
tion throws the muscles into action ; but the sudden removal of pressure, 
percussion with the points of the fingers, and quick motion of the part 
affected, increase the pain. The absence of severe constitutional symp- 
toms will assist the diagnosis, as will also the kind of respiration, which, 
in pleurodyne, is abdominal, in rheumatism of the muscles of the abdo- 
men, thoracic. When the diaphragm is affected, the respirations are 
short and catching, and acutely painful. 

Muscular rheumatism also attacks internal viscera, as the muscular 
texture of the heart, causing violent palpitation ; the muscular coat of 



LUMBAGO— GOUT. dot 

the oesophagus, giving rise to much pain in swallowing ; and the mus- 
cular substance of the impregnated uterus leading to severe pains, similar 
to labour pains. Many internal muscular pains are connected with flatu- 
lence, or are symptomatic of dyspepsia. 

LUMBAGO. 

- This disease occupies the mass of muscles in the loins, and, when 
severe, confines, the patient to bed. or obliges him to walk carefully with 
crutches, or with the assistance of others. The slightest motion causes 
excruciating agony. 

Diagnosis. — From disease of the kidneys, by the urine remaining 
unchanged in character, or yielding merely the common deposits ; and 
by the absence of symptoms of disease of the kidney. From lumbar 
abscess, by the absence of rigors, and of hectic fever, and by the nega- 
tive results of a careful examination of the part affected. [It should be 
borne in mind that collections of matter in the muscles of the back may 
point at the lower part of the back itself, at any part of the abdominal 
parietes, or below Poupart's ligament.] 

Treatment. — The general treatment is that of other forms of mus- 
cular rheumatism [see supra . The local treatment consists in cupping 
the loins, or in dry cupping, if the pain be very severe, followed by the 
emplastrum belladonnas. In less severe cases, an opiate liniment Form. 
126, 128), Emplast. opii, or Emplast. picis, may be kept applied to the 
back. 



PODAGRA— THE GOLT. 



Varieties. — 1. Regular gout ; 2. Misplaced gout ; 3. Atonic gout : 
4. Retrocedeut gout. 

Symptoms — The first paroxysm of gout generally comes on about 
two o'clock in the morning, with pain in the ball of the great toe of 
one foot (more rarely in the heel, ankle, or instep), accompanied by 
rigor, followed by feverish heat. The pain increases till it becomes 
perfectly excruciating, and is accompanied by extreme restlessness. The 
joint is, at the same time, exquisitely tender, so that the patient cannot 
bear the we : ght of the bed-clothes, or the slightest jar or movement in 
the room. The pain having attained its acme towards the following 
evening, ceases sometimes suddenly, sometimes gradually, about mid- 
night: a general moisture breaks out on the skin, the patient fails into 
a sound sleep, and in some cases wakes free from pain. But in the 
majority of cases, on awaking next morning, the parts, which were 
before so painful and swollen, are found of a deep red colour, tense and 
shining, the surrounding parts cedematous, and the vessels turgid. For 
several days and nights tie same lound of symptoms occur in a miti- 
gated form, till at length the redness and the swelling subside, the skin 



358 PODAGRA. 

desquamates, and the joint is either restored to its healthy state, or 
becomes the seat of the chronic form of the disease. 

It rarely happens that one fit of gout is not followed, at a longer 
or shorter interval (sometimes of months, sometimes of years), by a 
second attack. Most patients indeed have several successive attacks, 
which at first occur at the same season of the year, but at length take 
place very frequently, extending first to both feet simultaneously or in 
succession, then to the hands, and at length to almost all the joints. 
These subsequent attacks set in at all hours of the day and night, com- 
mence sometimes in the hand, sometimes in the foot, sometimes in the 
great toe or thumb, in other instances in the joints of the wrist or ankle. 
They are attended with less pain, but with more constitutional disturb- 
ance. At length, after repeated attacks, the joints become stiff, and in 
many cases they are the seat of chalky deposits. 

The fits of gout sometimes appear without warning, but they are 
generally preceded by dyspepsia, with its usual attendants, dejection of 
spirits, and irritability of temper ; or by unusual coldness and numbness 
of the 'extremities, alternating with a sense of pricking or formication, 
frequent cramps, and unusual turgescence of the veins of the leg. 

When the gouty diathesis prevails in the system, but without pro- 
ducing the usual inflammatory affection of the joints, it oiten appears 
as an affection of some internal part. If it attacks the stomach, there 
is great depression and anxiety, followed by intense gastralgia, nausea, 
vomiting, and eructations, frequently accompanied by pains and cramps 
of the trunk and arms. Sometimes there is obstinate constipation, some- 
times diarrhoea. If the heart be attacked, palpitation, syncope, and angina 
are the symptoms present ; if the lungs, dyspnoea, asthma, and some- 
times a persistent spasmodic cough. When the head is affected, there 
are headache and giddiness, followed sometimes by apoplectic and para- 
lytic affections. When it attacks the spinal cord, it gives rise to severe 
neuralgic affections, terminating in paralysis. These gouty affections of 
internal parts, without inflammation of the joints, have been termed 
misplaced gout, or atonic gout, on the supposition that the system had 
not strength to throw the disease out. 

Sometimes the inflammation of the joints having come on in the usual 
manner, but without attaining the usual severity, or continuing for 
the customary time, suddenly ceases, while the disease is transferred to 
some internal part. This is called retrocedent gout. 

Pathology. — A blood disease, caused directly by an excess of uric, 
acid in the blood. The local symptoms are due to the deposit of crys- 
talline urate of soda in the inflamed part, both on the surface of the 
synovial membrane, and within the substance of the cartilages and 
fibrous tissues themselves. 

Uric acid may readily be detected in the blood of persons predisposed 
to, or suffering from, gout. Add six di ops of ordinary acetic acid to a 
3j of the serum ; suspend a thread of cotton in the mixture, and after 
twenty-four or forty-eight hours, a string of minute rhombs of uric 
acid will be formed along the thread. (Garrod.) 



gout. 359 

Chronic gout sometimes results in one of the most inveterate forms 
of albuminuria, and the kidneys are found reduced to half their size 
and weight, shiivelled and granular, the cortex atrophied, and the 
pyramids streaked with white lines of deposited urate of soda, consti- 
tuting the " gouty tdduey" of Dr. Todd. 

Causes. — Predisposing and remote. The male sex; the adult age, 
and particularly the mid period of life (it seldom occurs before puberty, 
and in a large proportion of cases makes its first attack between 30 and 
40); hereditary predisposition ; plethoia; a full diet of animal food; 
fermented and especially malt liquors ; acid and acescent wines ; a 
sedentary and studious life; dyspepsia. Gout is not peculiar to the 
rich, but often affects poor persons of temperate habits after long 
piivation. 

Exciting. — Cold to the feet; fatigue; anxiety; excessive evacua- 
tions ; sprains and blows ; intemperance ; the ceasing of usual labour ; 
sudden change from a full to a spare diet ; the suppression of customary 
evacuations, as of the piles, which are common in gouty persons. 

Diagnosis. — From acute rheumatism, by the seat of the disease 
being the smaller joints, especially the great toe, while rheumatism 
attacks the larger joints. By the more intense colour of the inflamed 
part. By its more sudden attack. By the more fiequent and distinct 
remissions of fever and pain. By the itching and desquamation. By 
the absence of the profuse acid perspiration of acute rheumatism. Some- 
times by the age at which it occurs ; acute rheumatism being common 
in childhood, while gout is very rare before puberty. By the more 
rapid and complete convalescence. Gout occurs in those who live freely, 
and in persons of full habit ; rheumatism commonly in the debilitated. 
The metastasis from joint to joint, and the heart affections so common 
in acute lheumatism, are comparatively rare in gout. 

Prognosis. — Favourable. Youth, and an unimpaired constitution ; 
a first attack ; the more severe the paroxysm, the shorter its duration ; 
the longer the intei mission, the more effectual is the paroxysm in 
removing various anomalous diseases, to which the patient had been 
subject ; its not being hereditary. — Unfavourable. Impaired constitu- 
tion ; advanced age ; visceral affections ; hereditary predisposition ; 
the deposition of chalky matter in the joints: the disease suddenly 
leaving the extremities, and attacking the stomach, heart, brain, or 
lungs ; anasarca, or albuminuria, or both, combined. 

Treatment. — Indications. — 1. General. An attack of gout may 
be effectually shortened by a full dose of the Vinum colchici combined 
with opium (Form. 211) at bed-time; followed by a saline aperient in 
the morning; or, in the smaller dose (TY\xx) three or four times a day. 
When given in smaller repeated doses the colchicum and opium may be 
combined with a saline aperient, according to the state of the bowels. 
When a sufficient depressant effect has been produced, the colchicum may 
be omitted, and the saline diaphoretics (Form. 229, 295) prescribed. 



360 GOUTY CONCRETIONS. 

The exciting causes of the disease must be avoided by regular living, 
abstinence from fermented liquors, the moderate use of animal food. 
After the acute symptoms have subsided, we may direct friction with 
the flesh-brush ; regular and brisk exercise : Bath waters ; the regular 
use of mild aperients ; the occasional use of alkaline medicines ; and 
when dyspeptic symptoms are present, the treatment applicable to 
dyspepsia. Salts of lithia has been lately introduced as very suitable 
for the elimination of the gouty material. They promise to be useful. 
'See Form. 294.) 

2. The Local treatment consists in wrapping the inflamed part in 
flannel, wool, or fleecy hosiery, and keeping the limb as still as possible. 
Opium and atropine lotions may be used to alleviate the pain. 

Treatment of retrocedent Gout. — If the stomach be attacked, the 
liberal administration of stimulants, such as warm brandy and water, 
wine and aromatics ; aether, ammonia, camphor, and musk. Sinapisms 
should be applied to the feet, with a view of restoring the external 
inflammation. Other forms of retrocedent gout require the treatment 
appropriate to idiopathic affections of the same organs. 

Gouty Concretions. — Gouty concretions, chalk-stones, or topha- 
ceous deposits, consist chiefly of urate of soda, and are deposited around 
the joints, in the bursas mucosas, in the ligaments, aponeuroses, and 
cellular membrane, and even under the cut : cle. The pain which they 
occasion may be relieved by warm poultices. Great relief is also some- 
times experienced from applying: rings of blistering plaster above or 
below the swollen joints. The joints may also be treated with iodine 
paint. A narcotic cataplasm or anodyne fomentation often affords great 
relief. Benzoic acid, combined with a salt of potash, in doses of a 
scruple about an hour after each meal ; or benzoate of ammonia may be 
given and persevered in for a considerable period where extensive deposits 
have already taken place. The waters of Aix-la-Chapelle, Vichy, Toplitz, 
Marienbad — all of which contain lithia — should be taken in lieu of 
spirits, wine, or malt liquors. Sometimes suppuration occurs around 
the chalky joint. A foul ulcer results, and as the urate separates veiy 
slowly, the wound is healed with difficulty. It should be lightly dressed 
with a weak potash or lithia lotion. 



( 361 ) 



SPECIAL DISEASES. 



CHAPTEE I. 

DISEASES OF THE NERVOUS SYSTEM. 

1. Of the Brain. 

2. Of the Spinal Marrow. 

3. Of the Nerves of Sensation. 

4. Of the Nerves of Motion. 

5. General Disorders of the Nervous System. 

6. Mental Disorders. 

DISEASES OF THE BRAIN. 

Cephalalgia . . Headache. 
Encephalitis . . Inflammation of the Brain. 
Meningitis . . . Inflammation of the Membranes. 
Hydrocephalus . Water in the Head. 
Apoplexia . . . Apoplexy. 
Chronic Diseases of the Brain. 

CEPHALALGIA— HEADACHE. 

Headache is a symptom of almost all acute and chronic diseases of 
the brain, as well as a distinct functional derangement of very frequent 
occurrence. It may be (a) External, or (b) Internal. 

[a-.) External. — 1. Cephalalgia muscularis ; 2. Cephalalgia perios- 
teosa ; 3. Cephalalgia neuralgica. 

(6.) Internal. — 1. Cephalalgia congestiva; 2. Cephalalgia dyspep- 
tica, vel sympathetica. Cephalalgia organica. 

External,. — 1. Cephalalgia muscularis, or pain of the muscular 
covering of the head, affects the occipito-frontalis and temporal 
muscles. Diagnosis. — The pain is diffused over the head, is increased 
by motion of the eyebrows and jaws, by pressure, and by percussion 
with the fingers. It is generally accompanied by muscular pain in 
the neck, shoulders, or other parts of the body. Cause. — Exposure to 
cold. Treatment, — That of catarrh when recent, and that of muscular 
rheumatism when chronic. . . - - 



362 CEPHALALGIA. 

2. Cephalalgia per ■iosteosa. — Seat, the pericranium. Diagnosis. — 
The pain is commonly limited to one spot, and is increased by firm 
and deep pressure, but is little, if at all, affected by action of the 
muscles. It sometimes affects the periosteum of the face at the same 
time, so that the nose is tender to the touch ; and it frequently extends 
to other parts of the body, especially to the shin and sternum. When 
limited to one spot, it is commonly attended with swelling. Causes. — 
This form of headache is generally traceable to a syphilitic taint, and 
coexists with similar affections of other bones, syphilitic diseases of the 
skin, &c. The health also suffers. The appearance and expression of 
countenance are those familiarly known as Cachexia syphilitica. Treat- 
ment. — That of secondary syphilis. Iodide of potassium in five-grain 
doses is a valuable remedy in this form of headache. If the bone be 
affected, and matter formed, free incisions will be required, followed 
by the treatment prescribed in surgical works for the diseases of bone. 

3. Cephalalgia neuralgica vet periodica. — Seat, the nerves of the 
internal angle of the orbit and side of the nose {megrim), fixed in one 
spot, causing a sensation as if a nail were driven into the head {Clavus 
hystericus), or of one side, more commonly the left, of the head and 
face (hemicrania . It occurs with regularity at the same intervals 
as ague, and in some instances at the longer intervals of ten days, a 
month, or a year. In some cases the intermittent passes to a continued 
pain, and in many patients the disease is never distinctly intermittent, 
but is characterised by irregular intervals of perfect ease, and by being 
bounded by the central line of the head and face. The paroxysm may 
last for any period from an hour to two days. The disease is more 
common in women than in men, and in young than in old persons. 
But it may occur at any age. In the worst case the pain is of the 
most acute character, and is brought on by eating or speaking, or by 
draughts of air. Diagnosis. — The absence of tenderness, and of increase 
of pain on contraction of the muscles of the scalp, distinguish it from 
the first and second forms. 

Cause. — Exposure to cold and wet — marsh miasma. Treatment. — ■ 
The same as for ague, viz., quinine in large doses, or liquor arsenicalis 
("Form. 133). The latter remedy, cautiously administered, is to be pre- 
ferred. The general health must at the same time be attended to. 

Ixterxal. — 1. Cephalalgia congestica, or congestive headache. 
This presents itself in three different states of constitution — the 
plethoric, the delicate and irritable, and the weak and leucophlegmatic. 
Diagnosis. — Obtuse pain, affecting the whole of the head, especially 
the forehead and occiput, combined in the plethoric with a bloated 
countenance, a full red eye, distension of the veins, a full pulse, and 
a dull and heavy expression of face: in the delicate and irritable, with 
flashes of light, floating specs before the eyes, noises in the ears, cold 
extremities, and a small, frequent, quick pulse ; in ancemic subjects, 
with pale skin, lips, tongue, and gums, cold extremities, beating at the 
heart, violent throbbing of the carotid arteries, and small, frequent, 



HEADACHE. 363 

quick pulse. In the two latter classes of persons, it is brought on 
in severe paroxysms, by sudden noises, mental emotions, or violent 
muscular exertion. Treatment. — In the plethoric, that of plethora 
(p. 256). In the delicate and irritable, by repose of mind, careful 
attention to the state of the stomach and bowels, and sedative medi- 
cines taken at bed-time occasionally (Form. 256, 274). In anaemic 
subjects the treatment of anaemia (p. 260). 

A congestive headache allied to the first form (the plethoric) may 
be caused by narcotic and narcotic-acrid poisons ; and may occur at 
the onset of febrile disorders (attended in these cases by pain in back 
and limbs), at the onset of attacks of apoplexy, and in the early stage 
of phthisis (when it commonly affects the forehead). 

2. Cephalalgia dyspeptica vel sympathetica. — Sick headache. — 
Diagnosis. — From other headaches by the marked disorder of the 
stomach, or of the whole alimentary canal. Symptoms. — Pain usually 
fixed, in the left temple, over the right eye, or on the forehead, com- 
monly commencing when the patient first rises in the morning, and 
in slight cases continues till after breakfast ; in more severe ones, it 
begins as a diffuse heavy pain, and gradually becomes fixed in one spot, 
accompanied with nausea, flatulence, sour eructations, and vomiting. 
There is also confusion of thought, dimness and indistinctness of vision, 
and singing in the ears. Sometimes the fit is removed by free 
discharge of food, or of frothy mucus or bile from the stomach ; and 
this is sometimes accompanied, or followed by, diairhcea. Its duration 
varies from some hours to three or four days, and in confirmed cases 
it returns at short intervals, and is attended with great suffering. 
Sometimes there is much flatulence, and relief is only afforded by free 
eructation. Cause. — Derangement of the functions of the stomach and 
bowels. The abuse of aperient medicines, by which the tone of the 
alimentary canal is weakened. Sick headaches are common just before 
and after the menstrual period. Treatment. — Gentle aperients in 
combination with alkalies, as rhubarb with soda, or magnesia. Regu- 
lation of the diet ; proper exercise ; emetics, where the cause is tran- 
sient. In cases of obstinate sick headache, emetics of ipecacuanha may 
be administered every morning with the best effect. If large quantities 
of bile are ejected from the stomach (bilious headache), cholagogue 
purgatives (Form. 275) will be found useful. When the bowels are 
very irritable and act irregularly, an occasional dose of Gregory's 
powder, or rhubarb and bismuth. When much flatulence is present, 
turpentine or kreasote may be given. Cold to the head sometimes acts 
as a palliative. A draught containing from five to ten grains of car- 
bonate of ammonia given at the commencement of the attack will some- 
times arrest it. 

3. Cephalalgia organica. — Diagnosis. This pain is distinguished 
from the foregoing forms either by appearing to affect the entire brain, 
or by being fixed and deep-seated. It may be accompanied by dis- 
ordered digestion, but it is not relieved by vomiting. It is also subject 
to marked increase and decrease of severity, but rarely suffers a com- 



364 ENCEPHALITIS. 

plete intermission. The nature of the disease is at length made known 
by some marked disorder of the functions of the nervous centres, by 
paralysis, spasms, or convulsions. The pain is allied to the plethoric 
variety of congestive headache. Treatment. — That of the disease of 
which it is the symptom. The state of the circulation through the 
brain must be carefully watched, and local and general blood-letting, 
purgatives, and counter-irritants, must be resorted to; at the same 
time that strict attention is made to the state of the general health. In 
chronic inflammatory affections of the brain, a couise of mercury, 
carried to the extent of affecting the mouth, will sometimes effect a 
cure. 

Great caution is necessary in inquiring into the cause of headache, 
and in discriminating one form from another ; the treatment will 
entirely depend on the accuracy of the diagnosis. Sometimes, for 
instance, a patient complaining only of headache will be found to be 
suffering from phthisis pulmonalis. (G.) 



ENCEPHALITIS— INFLAMMATION OF THE BRAIX AND ITS 

MEMBRANES. 

Synonyms. — Phrenitis. Meningoencephalitis. 

Species. — 1. General, that is, involving the whole, or a considerable 
part, of the substance and membranes cf the brain. — 2. Partial, or 
affecting only a part of the substance, or. of the substance and mem- 
branes, of the brain. 

1. GENERAL INFLAMMATION OF THE BRAIN AND ITS MEMBRANES. 

- Symptoms. — This disease does not always commence in the same 
way. In one class of cases it begins with acute pain in the head and 
violent delirium ; in a second with nausea, bilious vomiting, and 
obstinate constipation; in a third with a paroxysm of general convul- 
sions; in a fourth, and very rare class, with loss of speech. 

The disease, when fully formed, is characterise 1 by excruciating 
pain in the head ; throbbing of the temporal and carotid arteries ; 
flushed face ; injected and brilliant eyes ; contracted pupil ; and a 
peculiarly wild expression of countenance. There is intolerance of 
light and sound, extraordinary acuteness of the senses, constant watch- 
fulness, want of sleep, fierce delirium, and convulsions. The skin is 
hot and dry, the pulse hard and frequent, sometimes full, sometimes 
contracted ; the tongue red and dry, or covered with a white fur ; there 
is intense thirst, with nausea and bilious vomiting ; and the bowels 
are obstinately confined. These symptoms belong to the stage of ex- 
citement, and continue for a variable period of from one to three days, 
when, gradually subsiding, they are succeeded by low muttering deli- 
rium, deafness, indistinctness of vision, insensible pupil, strabismus, 






GESEBAL INFLAMMATION OF THE BRAIN. 365 

twitchings of the muscles, tremors, relaxation of sphincters, occasional 
retention of urine, cold sweats: or by profound coma. 

In Insolation or sunstroke the disease is very rapid, and death may 
occur in from one to forty-eight hours from the seizure. The pupils 
are contracted and fixed, the breathing hurried. The symptoms of 
encephalitis soon pass into coma. Occasionally there are convulsions 
from the commencement of the attack ; but in the majority of cases the 
patient dies without making the slightest movement. 

Terminations. — When fatal, in coma: or in great prostration of 

strength, with typhous symptoms. Recovery may be complete, or the 
disease may end in mania, dementia, or paralysis. Its duration varies 
from one or two days to two or thiee w^eeks, or even more. 

Causes. — Excessive heat, or great vicissitudes of temperature ; the 
direct rays of the sun {coup d.e soleil) ; violent exercise; excited 
passions; intense stuly; irritating matter in the stomach; external 
violence : the abuse of spirituous liquids ; metastasis of gout, rheuma- 
tism, erysipelas, exanthematous fevers, dentition. Inflammation of the 
brain may also supervene on pneumonia, renal affections, and all febrile 
diseases, especially pyaemia. 

Diagnosis. — From mania, by the marked febrile symptoms and 
rapid course. From febrile delirium, by the delirium being a primary 
and not a secondary affection. From the effects of loss of blood, by the 
history of the case, the inflammatory symptoms, and the flushed face. 
From delirium tremens, also, by the history of the case, by the hot dry 
skin, and high fever, by the want of consciousness, and by the absence 
of the tremulous motions of the body and limbs, hi most cases of 
delirium tremens the face is pale and the skin moist ; the limbs tremble, 
and the patient can understand and answer questions. 

Morbid Anatomy. — Thickening of the arachnoid, effusion of 
serum, of lymph, of a mixture of the two, or of pus, under the arach- 
noid and into the meshes of the pia mater, or into the ventricles, with 
softening of their walls; the incised surfaces of the brain present 
numerous bloody points, the medullary surface is of a light pink hue, 
and the cineritious substance of an ashy red, not removed by washing : 
suppuration, softening, or hardening of the substance of the brain. 
In death from sunstroke, great engorgement of the lungs and light 
cavities of the heart will be usually found. 

Prognosis. — Favourable. The return of sleep and consciousness: 
a warm and equable perspiration; diarrhoea; haemorrhage from the 
nose ; diminished frequency, and greater fulness and softness of the 
pulse. If preparations of mercury have been given, the occurrence of 
salivation. — Unfavourable. Stupor, difficult deglutition, profouud in- 
sensibility, tremors, convulsions ; involuntary evacuations ; suppression 
of urine; pallor of the face. The mortality in sunstroke is oiten more 
than 50 per cent. 



366 PARTIAL INFLAMMATION OF THE BRAIN, 

Treatment. — I. During the period of excitement. Indication. 
To lessen the force of the cerebral circulation. 

(a.) By applying to the shaved head cold lotions constantly renewed, 
ice, or a stream of cold water. The latter is greatly to be preferred, 
especially when there is violent deliiiuni. 

(6.) By bleeding. — A copious and sudden evacuation of blood from 
a free orifice in the arm, in the erect or semi-erect position, to be re- 
peated, if necessary, proportioning the quantity 1o the age, sex, tem- 
perament, and habit of the patient ; followed, if necessary, by cupping 
or leeches to the temples, or by opening the temporal artery. 

(c.) By active purging at the outset with castor or croton-oil, or 
with a full dose of calomel and colocynth, and salivation, if possible, 
induced by half-grain doses of calomel every two, three, or four hours. 

(d.) By depressants, in doses short of inducing vomiting. Of these 
tartar-emetic is the best, in doses of a sixth to a fourth of a grain, given 
every hour until an effect has been produced upon the pulse. 

(e.) By counter-irritants to the extremities, such as the mustard- 
poultice, or a large bli-ter to the inside of the thighs, or hot water to 
the feet frequently renewed. 

(f.) By strict antiphlogistic regimen. The food should consist of 
barley-water, milk, gruel, arrowroot, and the like. 

(g.) By complete rest and peifect quiet. The sick-room should be kept 
dark and silent. The head and shoulders should be raised and kept cool. 

II. During the period of torpor. — Brisk purgatives may be given 
w T ith advantage, and the scalp freely blistered. 

In extreme collapse, ammonia, wine, and brandy must be given, wit* 
beef-tea and nourishing food, and opium or laudanum may be cautiously 
administered. If deglutition be imperfect, food and medicine must be 
given by the rectum. The state of the bladder mu*t be frequently 
ascertained, and, if there be retention, the water must be drawn ott two 
or three times a day. 

III. During convalescence. — The patient must be narrowly watched, 
the diet carefully regulated, and the bowels kept free by gentle ape- 
rients. He should not be allowed to resume his ordinary occupation 
till his health is quite re-established. In case of relapse, cold applica- 
tions to the head, counter-irritants, and more active purgatives should 
be resumed. If the mind does not recover its tone, the memory be im- 
paired, and the patient remains weak and irritable, the cold douche or 
the shower-bath every morning, with or without blisters to the scalp, 
or a seton in the neck or arm, may be resorted to. 

In the treatment of sunstroke the cold douche is very serviceable. 

2. PARTIAL INFLAMMATION OF THE BRAIN WITH OR WITHOUT 
IMPLICATION OF ITS MEMBRANES. 

Symptoms. — These are o r ten very obscure ; and vary with the e^ 
tent, degree, and progress of the inflammation, as well as with the part 
of the brain attacked. In most cases, the first symptom is pain in th 



PARTIAL INFLAMMATION OF THE BRAIN. do/ 

nead, more or less severe, rarely altogether absent, but subject to 
increase from causes affecting the circulation, and accompanied from 
the first, or followed after a time, by giddiness, singing in the ears, 
indistinct or disordered vision, numbness or increased sensibility of the 
fingers, of the hands and arms, or of other parts of the surface or' the 
body ; and slight convulsive movements of the limbs, with occasional 
attacks of nausea and faintness. The patient is restless and irritable, or 
suffers from depressed spirits ; the sleep disturbed, and the mind gene- 
rally more or less impaired. The circulation is very variable, the pulse 
being at one time slow and regular, and the countenance pale ; at 
another, the pulse frequent and the face flushed ; these opposite states 
often alternating with each other at short intervals. The patient 
suffers from nausea and anorexia, and is liable to frequent attacks of 
vomiting. As the disease advances these symptoms become more 
strongly marked, and rigid contraction of particular muscles or groups 
of muscles are superadded, occasioning squinting, distortion of the 
features, difficult and indistinct pronunciation of particular letters or 
words, and sometimes great difficulty in swallowing. When the muscles 
of the extremities are thus affected the limbs assume a flexed position, 
and any attempt to move them occasions great pain. The pupils gene- 
rally become less active, dilated, or unequal, and the sight of one or 
both eyes is impaired. In a still more advanced stage the partial con- 
tractions of the limbs are exchanged for very extensive and constantly- 
increasing loss of power and sensation, all the senses fail, the sphincters 
are relaxed, and the patient sinks utterly helpless and exhausted. 

The duration of this disease is extremely variable. It may assume 
from the first an acute character, and terminate fatally in a few days ; 
or it may run a chronic course of several weeks, months, or years ; or 
the chronic form may, at any time, be exchanged for an acute attack, 
with extensive inflammation of the membranes of the brain. 

In some cases general convulsions, usually stronger on one side of 
the body, may supervene. 

Morbid Anatomy. — Congestion of the affected portion of the 
cerebral substance; hardening of its' texture; white or red softening: 
small extravasations of blood ; infiltration of pus, contiguous to in- 
flamed or necrosed bone; encysted abscess; fatty degeneration, ossi- 
fication, or aneurism of the vessels; gangrene; a cystic entozoon sur- 
rounded by inflamed brain tissue; scrofulous tumours. The mem- 
branes will be found implicated according to their proximity to the 
seat of irritation or inflammation. The effusion of serum is common 
:to several of these conditions. In certain cases we may trace the local 
disease to the impaction of one of the cerebral vessels by a clot of 
i rine derived from an aneurism or diseased cardiac valve. 

Causes. — Some of those of encephalitis, such as the eruptive fevers 

i pyaemia. Scrofulous or syphilitic diseases of the bones of the 

d, blows on the head, entozoa. 

.Diagnosis. — From general encephalitis, by the partial character of 
-. rigidity, spasm, or paralysis. Only one side of the body, or a par- 



3G8 PARTIAL INFLAMMATION OF THE BRAIN. 

ticular limb or organ, may be thus affected. There may be merely 
inequality of the pupils, or squinting of one eye and double vision, or 
slight deviation of the tongue or uvula irom the median line, or 
numbness and twitching of a single limb may be the only indication. 

In forming our diagnosis of the exact seat of the disease, we must 
bear in mind the following facts : — 

1. Disease of the right side of the brain causes paralysis, or some 
disorder of the left side of the body, and vice versa. But to this the 
face is often an exception. According to Burdach, " in 28 cases of 
cerebral lesion of one side, the mu>c!es of the opposite side of the face 
we;e paralysed; in 10 cases those of the same side. Paralysis of the 
muscles of the eyeball occurred in 8 cases on the same side, in 4 on the 
opposite." The tongue is almost always paralysed on the side opposite 
to that of the face, and its extremity is pulled towards the paralysed 
side. 

2. So long as the disease is confined to the white substance of the 
cerebral lobes, and does not cause pressure on the surrounding parts, 
its presence is not manifested by disordered nervous function. 

3. Disease affectiug the right corpus striatum produces paralysis of 
motion on the left side of the body (left hemiplegia), and vice versa. 

4. Disease of the right optic thalamus results in paralysis of sensa- 
tion on the left side of the body, with more or less disorder of vision, 
and vice versa. 

5. Disease of the right eras cerebri, or right half of the Pons 
varolii, produces paralysis of motion and sensation on the left side of 
the body, and vice versa. 

6. A clot or tumour in the centre of the Pons varolii results in 
more or less complete paralysis of motion and sensation on both sides 
of the body, with disordered action of the muscles of the eyes and eye- 
lids, and interference with the auditory function. 

7. Disease affecting the right lobe of the cerebellum causes disordered 
motion on the left side of the body, and vice versa, with sensations of 
rolling in a particular direction, of going downwards or upwards, &c. 

8. A clot within, or pressure upon, the medulla is manifested by 
derangement of the functions of deglutition and respiration. 

Paralysis due to disease of the spinal cord is distinguished at a 
subsequent page. 

To return irom these general considerations to a diagnosis of the 
particular nature of the ceiebral disease: 

I. If symptoms of encephalic inflammation set in after chronic dis- 
charge of offensive matter from the ear, we may be pretty sure that 
caries of the petrous portion of the temporal bone has induced purulent 
inflammation of the contiguous part of the brain or its membranes. 

II. When a delicate scrofulous child becomes sleepy, heavy, and 
listless, and gradually lapses into a state of unconsciousness, with 
partial convulsive twitchings or clenching of the hand, grinding of the 



PAKTIAL INFLAMMATION OF THE BRAIN. 369 

teeth, squinting and uprolling of the eyes, we may generally conclude 
that a scrofulous tumour exists in the substance of the brain, or attached 
to its membranes. 

III. Vertigo, with sudden circumscribed pain in the head, followed 
by severe and repeated epileptiform convulsions, have been caused by 
the cystic entozoa. 

IV. Chronic abscess of the brain progresses most insiduously, e.g. 
A lad received a lacerated wound over the left frontal eminence. He 
was stunned for a few minutes, but soon recovered. Eight days after 
the accident he resumed work, and continued it uninterruptedly until 
three days before his death. The wound cicatrised by the thirty-second 
day* There were no head symptoms, not even a trace of pain ; the 
health and spirits were good, but he showed a little irritability of 
temper. On the thirty-ninth day he appeared pale and listless, and 
complained of pain in the epigastrium and sickness ; he had passed 
urine during sleep the preceding night, and he faltered once in walking 
to the infirmary, as if he had lost for a moment the use of his limbs. 
He again wetted the bed at night, and the next day lost the use of his 
right side. The following morning the power of deglutition was gone, 
and by 4 p.m. he had gradually lapsed into complete coma, with 
stertorous breathing, and a slow, laboured, irregular pulse. He con- 
tinued in this state until 3.30 p.m. next day, and then died. A thick- 
walled abscess, containing six ounces of thick greenish matter, occupied 
the anterior lobe of the left cerebral hemisphere, distending the mem- 
branes. 

Since abscess of the brain from external violence may thus insiduously 

progress under the eye of the medical practitioner, we can scarcely hope 

to receive timely intimation of the presence of the disease when it 

arises from some internal cause, unless, indeed, it involve one of the 

• centres of sensation or motion, or the root of a particular nerve. 

Apoplexy and partial softening of the brain may arise in people 
beyond middle age from disease of the blood-vessels. 

Prognosis. — Unfavourable in every stage of the disease, but espe- 
cially when rigid contractions or paralysis have set in. 

Treatment. — Will be indicated by the cause ; that of encephalitis 
generally, but less active. If there be great heat of the head, cupping 
or leeches will be required. In milder cases, blisters behind the ears 
or to the nape will suffice. In chronic cases a seton may be established 
at the back of the neck. The daily use of gentle saline aperients to 
keep the bowels in free action, a spare diet, and rest of mind and body. 
When the meninges are involved the constitutional effects of mercury 
may be induced with advantage. 



2 B 



( 370 ) 

MENINGITIS— INFLAMMATION OF THE MEMBRANES OF 
THE BRAIN, 

SYNONYM. — Arachnitis. 

Symptoms. — Inflammation of the arachnoid and pia mater com- 
mences differently in different cases. Sometimes it begins with sudden 
and violent pain in the head, with loud screaming, followed by con- 
vulsions. In other instances it commences suddenly with a long- 
continued paroxysm of general convulsions. In a third class of cases 
the attack is less sudden, the convulsions being preceded for two or 
three days by a general feeling of discomfort, slight headache, nausea, 
and vomiting. The pulse is generally quickened, but is sometimes less 
frequent than in health. When the disease is fully formed, the leading 
symptoms are acute pain, often expressed by sharp, piercing cries, and 
increased by motion ; intolerance of light and sound ; grinding of the 
teeth, sleeplessness ; furious delirium; a flushed face and suffused eyes. 
Twitchings and convulsions are commonly present, and sometimes 
strabismus ; vomiting is common ; the bowels are usually confined ; 
and the disease, when fatal, generally terminates in coma. 

Inflammation of the dura mater sets in with pain in the head, fever, 
and rigors, which often recur at regular intervals, and simulate ague. 
The intellectual faculties are at first but little affected, but during the 
progress of the disease the patient often falls into a state of coma. If 
the inflammation extend to the other membranes, or to the substance of 
the brain, the symptoms proper to inflammation of those parts show 
themselves. This disease is rarely idiopathic, but follows on injuries to 
the scalp or skull, or on inflammation of the ear. 

Causes. — Meningitis is often the chief symptom in the progress of 
the infectious fevers. It is commonly the first result of exposure to 
the direct rays of a burning sun. In childhood the most common 
cause is the deposit of tubercle upon the surface of the membranes 
constituting the variety known as "Tubercular Meningitis." (See 
p. 372.) 

Treatment. — Distinguish the cause and treat accordingly. Against 
sunstroke (Insolatio, coup de soleil) the cold douche must be applied to 
the head ; stimulants freely exhibited. The room should be darkened, 
and the head and spinal region blistered. 

The meningitis of fever requires the treatment described under 
Typhus. 

In tubercular meningitis we must be chaiy in the abstraction of 
blood ; and, if safe to do so, avoid it altogether ; otherwise the treat- 
ment will be that recommended under Acute Hydrocephalus. 



( 371 ) 

HYDROCEPHALUS— WATER IN THE HEAD. 
Varieties. — 1. Acute; 2. Chronic. 

1. ACUTE HYDROCEPHALUS. 

Symptoms. — This disease, like inflammation of the brain and its 
membranes in the adult, varies in its onset. Sometimes it is preceded, 
for a considerable period, by languor, inactivity, loss of appetite, nausea, 
vomiting, parched tongue, hot dry skin, flushing of the face, and other 
symptoms of pyrexia, or by the symptoms of infantile fever. (See 
p. 332.) In a second class of cases, it begins suddenly with the 
symptoms of inflammation of the brain and its membranes. (See 
p. 370.) In a third class of cases, it comes on obscurely, in the course 
of febrile disorders or of the exanthemata. 

The disease itself is characterised by acute darting pains in the head, 
with heat of scalp ; great sensibility to light, suffused redness of the 
eyes, flushed countenance, and hot and dry skin. The pupils are con- 
tracted, and the brows knit. The patient is very restless, moans inces- 
santly, tosses about, and rolls the head from side to side. The sleep is 
short and disturbed by a start or scream. The gait is tottering, and 
the hand is often raised to the head. The pulse is accelerated, hard, 
and quick : the respiration hurried and sighing. The 'tongue coated ; 
there is nausea or vomiting ; the bowels are either obstinately confined, 
or unusually loose, with foetid evacuations ; and the urine is scanty. 
Delirium and convulsions are sometimes combined with these symptoms 
of the stage of excitement. In infants there is at first strong pulsa- 
tion of the fontanelles. Afterwards they become tense and bulged 
outwards. 

After a longer or shorter period, the symptoms become less violent, 
the pain is less acute, the patient keeps up a low moaning ; an uneasy 
sleepiness succeeds a constant state of watching; the pupils are dilated, 
and strabismus is often present ; the muscles of the fore-arm are rigid 
and occasionally convulsed ; the fingers are clenched upon the thumb ; 
the pulse is now preternaturally slow and often intermitting, but sub- 
ject to great and sudden acceleration on change of posture ; and the 
respiration is more frequently interrupted by deep sighs. The strabis- 
mus increases ; the pupils become more dilated and cease to contract on 
being exposed to light ; and double vision or complete loss of sight, 
with lethargic torpor, succeed. 

In unfavourable cases the pulse resumes its quickness, and becomes 
extremely small and rapid : the respiration is difficult or stertorous ; 
the limbs are convulsed or paralysed ; the skin is covered with a cold 
sweat; the evacuations become involuntary; and at length the patient 
expires in convulsions, comatose, or exhausted. 

Acute hydrocephalus in the adult. — This is a rare occurrence, hydro- 
cephalus being peculiarly a disease of infancy and childhood. But 
Heberden relates the following case: — "An adult was seized with in- 



372 ACUTE HYDROCEPHALUS. 

tolerable pain of the head, sometimes had a voracious appetite, and 
sometimes none ; became delirious, convulsed, stupid, and died : the 
ventricles of the brain weie found so distended with water, that as 
soon as a puncture was made the water flew out to a considerable dis- 
tance." (This is probably a case of hydatid tumour.) 

Terminations. — In slow recoveiy; in death; or in chronic hydro- 
cephalus. 

Morbid Anatomy. — Sometimes enlargement of the head, separa- 
tion of the sutures, and protrusion of the membranes. Serum, limpid 
or turbid, in the ventricles of the brain or beneath the membranes ; 
softening of the surrounding cerebral substance ; flattening of the con- 
volutions ; masses of tubercular matter imbedded in the substance of 
the brain. The pia mater unusually vascular ; the arachnoid opaque ; 
minute semi-transparent or opaque bodies, single or in patches, in the 
substance of the pia mater, or larger portions of tuberculous matter 
from the size of a millet-seed to that of a pea deposited upon the 
surface of any of the membranes {tubercular meningitis). 

Causes. — Predisposing. Infancy and childhood ; debility ; scrofu- 
lous diathesis. — Exciting. Intestinal irritation; dentition; extension 
of inflammation from the ear ; febrile and exanthematous disorders ; 
premature application to study. — Proximate. In the greater number 
of instances tubercular deposits in the pia mater, giving rise to inflam- 
mation of the membranes. 

Diagnosis. — Heat of the head, distension of the fontanelle. Spasm 
and twitching of the muscles, or actual convulsions, are the distinguish- 
ing marks ; followed by strabismus, dilated pupil, and profound 
stupor. The tubercular nature of the disease may be suggested by 
hereditary tendencies, by the actual presence of tubercles in the lungs, 
or other manifestations of the scrofulous diathesis, such as enlarged 
cervical glands. It is necessary to distinguish this disease from one of 
an opposite character, called spurious hydrocephalus, which has the fol- 
lowing characters : a pale cheek, a cool or cold skin, an expression of 
great languor, and an absence of febrile symptoms, or, at the most, an 
occasional and transient flushing of the face ; to which may be added, 
in the case of infants, a sunken instead of swollen fontanelle. On 
inquiry, the child will be found to have suffered from loss of blood, 
from long-continued diarrhoea, or from some other exhausting dis- 
charge. 

Prognosis. — Very unfavourable ; especially if there be squinting, 
weak intermitting pulse, great enlargement of the head, apoplectic 
stertor, difficult respiration, and involuntary evacuations. 

Treatment. — The general treatment will be that appropriate to 
Inflammation of the Brain (see p. 366), due regard being paid to the 
strength and constitution of the patient, and to the existence of any 
particular source of irritation. If the disease be general and acutely 
i inflammatory, small doses of grey powder may be given every three 



CHRONIC HYDROCEPHALUS. 373 

hours. If the gums be hot and swollen they should be freely lanced, 
and a leech may be applied to the mouth or behind the ear. In the 
threatening convulsions and insomnia of dentition, conium is a valuable 
remedy.* When the disease is protracted and the scrofulous diathesis 
well marked, we must abstain from the continued use of mercurials 
and trust to local treatment, to aperients and to sedatives. 

The local inflammation should be treated by the application of cloths 
wetted with cold water, vinegar and water, iced water, or the spirit 
lotion to the head. Cold water may be dropped on the slightly raised 
head, while the body and extremities are immersed in warm water. 

2. Counter-irritants, such as mustard poultices or blisters to the 
temples, back of the ears, or neck, may be simultaneously used. 

2. CHRONIC HYDROCEPHALUS. 

Symptoms. — Children are sometimes born with this disease. It 
rarely occurs in the adult ; but Dean Swift died of it, and other cases 
are on record. It takes place at all periods between birth and the 
eighth year, seldom after. When it occurs after birth it comes on 
slowly and insidiously ; or it follows the acute form. Its presence is 
indicated by drowsiness, languor, strabismus, vomiting, costiveness, 
coma, and convulsions ; the bones of the head separate, the fontanelies 
enlarge, and the head acquires an enormous size. The patient may 
survive, in spite of immense enlargement, for months or even years. 

Causes. — 'Predisposing. The scrofulous diathesis. — Exciting. 
Injury to the brain during labour ; tumours within the cranium ; the 
causes of other dropsies ; dentition ; irritation in the intestinal canal. 
It is also a consequence of the acute form. 

Diagnosis. — The history of the case, the large size of the head, and 
the prominence of the fontanelies. 

Parents often express anxiety about the large size of their children's 
heads, supposing that the enlargement is due to water in the head. 
As this question is often put to the medical man, it is well that he 
should be cautioned not to attribute a large head to this cause, unless 
there are other decided symptoms of the disease. 

Prognosis. — The disease generally ends in death, with convulsions. 
If the bones yield and separate, its fatal termination is protracted. 

Treatment. — Indications. I. To promote the absorption of the 
effused fluid. II. To improve the health. 

(a.) Blisters to the head, kept open for days or weeks by cantharides 
or savine ointment ; frictions with tartar-emetic ointment ; or an issue 
over the fontanelies. The anterior fontanelle has been punctured at 
the side of the longitudinal sinus, and much serum withdrawn in 
several cases, but the results have not been such as to justify the 
operation. Pressure by means of adhesive plaster, and the constant 

* See the Editor's work on the use of Conium, &c. 



374 APOPLEXY. 

application of cold, may retard or altogether prevent the further 
effusion of fluid, until the sutures are well knit. 

(6.) Mercury ; applied externally, and given internally, until con- 
stitution symptoms are evident. In constitutions tainted by syphilis 
and scrofula, the perchloride and iodide of mercury are appropriate. 

A light nutritious diet and a little wine may be given at short in- 
tervals throughout the day. Warmth and a change of air, especially 
if the patient live in a low and damp situation, to the sea-side, or a 
dry and bracing inland spot. 

Tonics — sulphate or iodide of iron, or Vinum ferri according to the 
age ; and the mineral acids. 



APOPLEXIA— APOPLEXY. 

Definition. — Sudden loss of motion, with more or less derange- 
ment of perception, and sensation caused by injurious pressure upon 
the brain with or without rupture of some of its fibres. 

Varieties. — 1. Simple or congestive; *. e., congestion of the vessels 
of the brain without rupture ; 2. Serous, or congestion with serous 
effusion; and, 3. Hemorrhagic, or congestion with ruptuie. 

Symptoms. — This disease makes its attack in one of three ways : — 
1. Suddenly, the patient falling down without warning, as if from a 
blow. 2. After a short premonitory stage, consisting of acute head- 
ache, sickness, and faintness. 3. With sudden hemiplegia. 

In the first form of the disease, and when there is much blood 
effused, the patient falls to the ground, foaming at the mouth, his neck 
swollen, his face livid, his pupils dilated, and the mouth slightly 
drawn to one side. The urine and faeces are discharged involuntarily, 
the extremities are cold and livid, the skin bathed in a cold sweat, and 
death may take place in a few minutes. 

When the quantity of blood is moderate, the fit is characterised by 
more or less stupor, and a slow and noisy, or stertorous and puffing 
breathing; difficult deglutition; flushed and livid countenance; pro- 
minent and motionless eye, and, generally, unequal pupils. The limbs 
are either motionless, rigid, or convulsed ; these effects are usually 
more marked on one or other side. The bowels are either obstinately 
confined, or the evacuations are passed involuntarily; the urine also 
is either passed involuntarily, or, being retained till the bladder is full, 
dribbles away. The pulse is full, strong, and quick ; but often less 
frequent than natural. 

In slighter cases the patient does not lose consciousness, and the 
speech is only slightly and transiently affected. In other cases the 
chief indication of the paralytic seizure is loss or derangement of this 
faculty. 

Apoplexy is sometimes preceded for a considerable period by pre- 
monitory symptoms, such as giddiness, headache, a sense of pressure 
in the head, confusion of ideas, incoherence, loss of memory, faltering 



APOPLEXY. 375 

speech, flushing of the face, haemorrhage from the nose, flashes of light, 
noises in the ear, illusions, double vision, transient blindness or deafness, 
drowsiness, numbness of the extremities, pallor, nausea, vomiting, and 
faintness. 

Terminations. — Suddenly in death. In death, after a variable 
interval. In complete recovery, which is commonly preceded by 
vomiting and profuse perspiration. In partial recovery, with more or 
less impairment of mind, and more or less extensive paralysis. 

Morbid Anatomy. — In congestive or simple apoplexy (distension 
of the vessels of the brain, with or without effusion into the ventricles, 
or at the base). In serous apoplexy (effusion of serum into the ventricles, 
or between the membranes). In hemorrhagic apoplexy (effusion of 
blood into the substance of the brain, into the ventricles, at the base, 
or on the surfaced 

The softest and most vascular parts of the brain are those in which 
haemorrhage is most liable to occur. In 444 cases tabulated by Dr. 
Aitken, the haemorrhage happened 268 times in the corpora striata ; 
39 in the thalami optici; 81 in the lobes of the cerebrum; 22 in the 
pons Varolii ; and 34 in the other parts of the encephalon, being at the 
respective rates of 60, 8, 20, 5, and 7 in the hundred. We often 
meet with evidence of a seizure previous to the fatal attack, such as a 
recent clot with circumscribed inflammatory softening of the nerve 
substance around it ; or an old contracted colourless clot containing 
blood crystals ; or a small cicatrised cavity containing a little serum. 

Diagnosis. — From the effect of spirituous liquors, by the odour of 
the breath. From the ordinary effect of narcotic poisons, by the 
history of the case. From both by some difference in the motor power 
of the two sides of the body ; e. g., one pupil may be contracted, and 
respond to the stimulus of light, when the other is dilated and immove- 
able; the muscles of the extremities on one side will generally be found 
perfectly flaccid, and the arm or leg falls from the hand like a mass of 
inanimate matter, while the muscles of the extremities on the other 
side will be found to be more or less rigid. If the limbs be convulsed, 
the movements on the two sides will, on careful examination, be found 
to be unequal. Sooner or later some such positive evidence of localised 
injury to the brain will be manifest. In order to make a correct 
diagnosis of the exact seat of injury, and form a just prognosis, atten- 
tion must be paid to the facts enumerated in the diagnosis of partial 
encephalitis. (See p. 368.) 

Prognosis. — Favourable. Youth ; slight impairment of the intellect 
and senses ; haemorrhage from the nose or haemorrhoidal vessels ; diar- 
rhoea ; profuse perspiration ; a pulse of natural frequency and character ; 
natural breathing. — Unfavourable in proportion to loss of conscious- 
ness; a full, hard, jerking pulse; loud stertorous breathing, with a 
puffing out of the cheeks ; repeated shiverings, followed by high fever ; 
repeated vomitings ; spasm, rigidity, or convulsions ; involuntary eva- 
cuations; retention of urine ; cold extremities; cold and clammy sweats. 



o7G APOPLEXY. 

Causes. — Predisposing. A certain age: from the fiftieth to the 
eightieth year: the liability increases as age advances. Few cases 
occur under twenty, and very few indeed in infancy and childhood. A 
certain make of body, combining a short thick neck, large chest, florid 
complexion, and stout person ; but the disease often occurs in persons 
of the opposite conformation. Hereditary tendency ; a sedentary life 
with overfeeding ; suppression of usual evacuations ; plethora, however 
induced : diseases of the valves of the heart preventing the. free return 
of blood from the head. The chief proximate cause is disease of the 
blood-vessels of the brain, the several stages of which appear to be 
fatty degeneration, atheroma, and ossification of their walls. (See 
Atheroma.) When the coats of the blood-vessels are thus diseased, they 
lose their elasticity and contractility, and become dilated and attenuated, 
and in this condition the least excitement of the circulation causes 
increased fulness and a tendency to rupture. 

Exciting. — Violent exercise; stiong expiratory efforts, as in singing 
and playing on wind instruments ; straining at stool ; fits of coughing ; 
sudden and violent emotions ; exposure to intense cold or heat ; long 
stooping, or suddenly rising from the stooping posture ; pressure on 
the neck ; venereal excitement ; intemperance ; narcotic poisons, such 
as opium ; suffocation by drowning, hanging, or strangulation, or by 
the narcotic gases, especially carbonic acid and carbonic oxide. 

Treatment. — During or immediately after the fit, first loosen the 
patient's neckerchief and shirt-collar, raise his head, or place him, if 
convenient, in a chair, and open the window of the apartment. When 
the face is turgid and the eye injected, or, the face being pale, the 
pulse is full, hard, and jerking, we may open a vein in the neck or 
arm, or partially divide the temporal artery, and allow the blood to 
flow till the approach of syncope, taking care that the patient does not 
faint. But when the face is pale, and the pulse feeble and intermittent, 
the patient must be treated as if he were in a fainting fit, and the 
bleeding must be postponed till decided reaction has occurred, and the 
symptoms just stated have shown themselves. 

In the after-treatment, the indication is to reduce the action of the 
heart, and diminish the force of the circulation through the brain. 

1. By bleeding from the arm at intervals, from a small orifice, in 
the semi-erect position, and with constant reference to the effect pro- 
duced upon the pulse and aspect of the patient, whenever and so long 
as there are evidences of fulness of blood, or excitement of the cir- 
culation. 

2. The application of leeches and cupping-glasses to the head and 
neck. 

3. Drastic purgatives, of which croton oil, in doses of one or two 
drops, is the most easily used and most efficacious. Purgative enemata. 

4. Cold to the head, if there be increased heat. 

5. Blisters to the nape, and, after a time, to the scalp. 

6. A diet, consisting at first of farinaceous food, passing to a more 
generous diet cautiously and gradually. 



APOPLEXY. 377 

7. If the disease take place soon after a full meal, an emetic must be 
employed ; or an attempt' mast be made to evacuate the stomach by 
tickling the fauces with a feather. 

If the menstrual or hemorrhoidal flux have been suppressed, leeches 
should be applied to the vulva, or verge of the anus. When there is 
profound coma or collapse, we may apply liniment (Form. 34) to the 
nape, and strong ammonia to the nostrils, and use a stimulant enema 
(Form. 72). The hot air-bath, or stimulants, in such cases, have pro- 
duced reaction ; and when this happens, depletion may be necessary. 

When apoplexy supervenes after a retrocession of gout or of acute 
rheumatism, brisk aperients should be given without delay. 

If the patient swallow with difficulty, great care is required in giving 
food to prevent suffocation. While the difficulty lasts, medicines should 
be unirritating and not bulky, and nourishment be given by teaspoon- 
fuls. The bowels should also be relieved by purgative clysters, and 
we must carefully anticipate retention of the urine. 

When convalescence commences, we may insert a seton in the neck. 
On the repetition of the fit, we must again resort to the treatment re- 
quired in the first attack, but in a less active form. When a patient 
suffers from sleeplessness and great irritability, opium is the appropriate 
remedy ; but it is contra-indicated in the early stages of apoplexy. 

In the treatment of apoplexy, in all its stages, we must not carry 
depleting measures to an extreme. Undue activity in this respect may 
lead to fatal consequences. Severe antiphlogistic measures are also 
decidedly contra-indicated in aged and feeble persons, in whom it will 
suffice to keep the bowels somewhat more open than usual, and to regu- 
late the diet, giving wine and other stimulants, according to the state 
of the pulse. 

Prophylaxis. — As apoplexy depends on a determination of blood to 
the head, and generally on a plethoric habit, persons predisposed to the 
disease should abstain from fermented liquors, observe moderation in 
the use of animal food, and carefully avoid indigestible food. In some 
cases, a vegetable or milk diet must be insisted on ; and on the recur- 
rence of threatening symptoms, a greater strictness of diet, and purga- 
tives ; and if these do not remove the symptoms, dry cupping to the 
neck, or the abstraction of blood by cupping from that part, must be 
resorted to. Hot rooms and late suppers must be avoided. The patient 
should take regular exercise in the open air, be abstemious in his habits, 
keep the bowels free, and w T ear nothing tight about the neck or chest. 
When the disease occurs in persons of weak constitution, a light nutri- 
tious diet, with a moderate allowance of weak stimulants, combined with 
astringent chalybeates or acid tonics, should be persevered in. Mental 
labour must be abandoned, and all excitement avoided. For the treat- 
ment of paralysis following apoplexy, see Paralysis. 



( 378 ) 



CHRONIC DISEASES OF THE BRAIN. 

There are several chronic diseases of the brain, such as softening, 
atrophy, induration, hypertrophy. The symptoms and diagnosis of 
these diseases are extremely obscure and ul certain, and the same 
symptoms may be present in very different states of the organ. 

In many cases chronic diseases of the brain are unattended with any 
symptoms which could lead us to suspect their existence. Thus, Louis 
states, that out of twenty cases of fungus of the dura mater, three only 
had cerebral symptoms of any kind : and abscesses, hydatids, cysts, 
exostoses, &c, sometimes attain great size, without any attendant 
symptoms of cerebral disorder. 



I. Softening of the Brain. 

Symptoms. — Those of failing intellectual and physical powers, gra- 
dually lapsing into imbecility. The gait becomes shuffling and un- 
steady, the grasp weak, the speech thick, slow, and imperfectly articu- 
lated (aphemia, aphasia), pointing, according to some observers, to the 
implication of the anterior convolutions of the brain, which rest upon 
the supra-orbital plates of the frontal bone. The memory is defective, 
and the animal functions torpid. A sensation of numbness and pricking 
affects the extremities of the weaker limbs. The radial and temporal 
arteries are seen and felt to be tortuous and hard. An " areas senilis " 
frequently surrounds the cornea. The patient is liable to attacks of 
apoplexy. His spirits are usually depressed, and he sits down at one 
time listless and apathetic, and at another sheds tears without being 
able to assign any cause for bis grie£ More or less paralysis accom- 
panies this condition. 

Termination. — Sooner or later in serous or sanguineous apoplexy. 

Morbid Ax atomy. — Brain matter less vascular, softer and whiter 
than usual. Its softness is such that a gentle stream of water makes 
an impression upon it and after a time causes its diffluence. In extreme 
cases it is senii-fjuid, and has little more consistence than cream. 
According to Dr. Todd, " the presence of great numbers of large cells, 
containing oily matter in large globules, and also in a state of minute 
subdivision, is characteristic of a state of white softening of some dura- 
tion." In all cases the blood-vessels will be found diseased. The con- 
dition of the radial and other arteries may be taken as an indication of 
that of the carotid within the brain. Sometimes its primary branches 
will be found dilated, thin, and stiffened here and there by patches of 
atheromatous deposit ; sometimes converted into moniliform osseous 
tubes. If the softened brain-pulp be washed away, a network of ather- 
omatous or bony tubes will be left. 






DISEASES OF THE SPINAL COKD AND ITS MEMBRANES. 379 

CAUSE. — Defective nutrition of the brain, resulting from disease of 
the coats of the blood-vessels. Partial softening is occasionally caused 
by the plugging of one of the large arteries or its branches by a clot of 
lymph detached from an inflamed cardiac valve, or derived from an 
aneurismal sac. 

Prognosis. — Unfavourable. 

Treatment. — Gentle exercise in dry temperate air, light nutritious 
albuminous diet, with a liberal allowance of wine. Dilute nitric and 
phosphoric acids in combination with bitter infusions, perchloride of 
iron and salts of zinc given for a week or two alternately. The patient 
should sleep with the head and shoulders slightly raised. All excite- 
ment, mental and physical, must be carefully avoided. 



II. Atrophy of the Brain, 

Shrinking of the cerebral hemispheres with complementary effusion 
of serum around it, or within its ventricles, is a condition very com- 
monly found in those who have been insane. 



III. Induration of the Brain. 

Induration appears to be the result of chronic inflammation ; the 
nerve tissue is harder than usual. In some cases the hardening is 
considerable, it is pearly white, less vascular than usual, and of the 
consistence of boiled white of egg. The induration may be partial or 
general. Convulsive movements are common in the course of the 



IV. Hypertrophy of the Brain 

Is allied to hydrocephalus, and arises in those of scrofulous habit. 
The consistence of the brain is softer than usual, the convolutions 
flattened, and the ventricles diminished in size. The progress of the 
disease is marked by pallor, anorexia, listlessness, occasional headache 
and giddiness. The child is ultimately taken with convulsions which 
continue till death occurs. 






DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 
Myelitis .... Inflammation of the Spinal Cord. 
Spinal Meningitis . . Inflammation of its Membranes. 

Other Diseases of the Spinal Cord. 

General Remarks. — While hemiplegia is the most obvious symp- 
tom of lesion of the brain, paraplegia is the most striking characteristic 



380 INFLAMMATION OF THE SUBSTANCE OF THE CORD. 

of injury to the spinal cord. In diseases of the brain the intellect and 
special senses are more or less implicated ; in diseases of the spine they 
remain throughout altogether unaffected. 

In the diagnosis of the seat of disease in the spinal cord, attention 
must be paid to the following facts : — 

1. Complete transverse section of the posterior columns of the cord 
results in loss of power to regulate the movements of the parts below 
the section. Partial injury is followed by incomplete control over the 
muscular movements. Hyperesthesia occurs in both cases in the parts 
below the section. 

2. Transverse section of the antero-lateral column produces paralysis 
of motion in the parts below the section on the same side of the body. 

3. Transverse section of the whole of the grey central nervous 
matter causes loss of sensation in all parts below the section. Transverse 
section of the right half of the grey matter results in loss of sensation 
of the left limb below the section, and hyperesthesia in the right limb, 
and vice versa. 

4. Whence it follows that transverse section of one entire half of 
the cord causes in the parts below the section paralysis of motion with 
hyperesthesia on the same side, and loss of sensation only, on the 
opposite side. 

5. If inflammatory irritation be present in the seat of the disease, 
the paralysed limbs will be rigidly contracted. In non -inflammatory 
diseases, or when inflammation has pas.-ed away, the muscles will be 
flaccid. 



MYELITIS— INFLAMMATION OF THE SUBSTANCE OF 
THE CORD. 

Symptoms. — Dull aching pain in the part affected, with some ten- 
derness ; loss of sensation and voluntary motion ; or numbness and 
impaired sensibility, with feebleness of the upper or lower extremities, 
or of both, or of a single limb ; or loss of sensation in one extremity, 
and of voluntary motion in another. The palsied limbs waste ; but the 
reflex function remains intact. The muscles of the affected limb may 
be relaxed, contracted, or convulsed. Sooner or later, retention or 
incontinence of urine comes on, the motions pass involuntarily, and bed- 
sores are formed on the back and hips. At last the patient sinks 
exhausted, or dies comatose from the extension of the disease to the 
brain. The symptoms vary with the seat of the disease. 

When the cervical portion of the spine is affected, the arms are 
paralysed, and there is difficulty in swallowing and in breathing, and a 
sensation of tightness around the chest, and in the epigastrium. The 
pulse is sometimes very slow. Priapism is often a troublesome 
symptom. 



INFLAMMATION OF THE MEMBRANES OF THE COED. 381 

When the dorsal portion is affected, the body is sometimes agitated 
by continued convulsive motions, and there are palpitations, difficult 
respiration, and sense of constriction in the abdomen. 

When the lumbar portion is attacked, the upper extremities and the 
breathing escape, but the lower extremities are paralysed ; and there 
is retention, followed by incontinence, of urine, and constipation, fol- 
lowed by involuntary evacuations from the bowels. Impotence is some- 
times a consequence of disease of this part of the spinal marrow. 

In some cases the disease comes on insidiously, is unaccompanied by 
pain, and makes slow progress, but is finally succeeded by paralysis of 
the bladder, rectum, and inferior extremities. 

Morbid Ax atomy. — Inflammation ending in hardening, creamy 
softening, or abscess of the cord, partial or complete. 

Causes. — Predisposing. The adult age, and male sex. — Exciting. 
Blows and falls ; violent exertions ; exposure to wet and cold. Caries 
of the vertebras ; scrofulous disease. Venereal excesses. 

.Diagnosis. — From other disease of the spinal cord, by the more 
complete loss of sensation in the paralysed parts. The grey matter is 
the conductor of sensitive impressions, and, being the most vascular 
part, it is most liable to inflammation. 

Prognosis. — Complete recovery is rare : but the disease may con- 
tinue for years. 

Treatment. — In the early stage, leeches or cupping to the part- 
affected, followed by counter-irritation in the neighbourhood of the 
part, by blisters, issues, or setons. Aperient medicines ; rest ; constant 
attention to the state of the bladder, and scrupulous cleanliness, 
throughout the disease. The patient should lie upon a water-cushion. 
The general treatment must be adapted to the state and strength of 
the patient. 



SPIXAL MENINGITIS— INFLAMMATION OF THE 
MEMBRANES OF THE CORD. 

Synonym. — Spinal arachnitis. 

Varieties. — 1. Acute spinal meningitis. 2. Subacute spinal 
meningitis or spinal irritation. 3. Rheumatic spinal meningitis. 

1. ACUTE SPINAL MENINGITIS. 

Symptoms. — Pain in the part affected, increased by motion, percus- 
sion, pressure, or heat. The pain, which often closely resembles that 
of rheumatism, and is brought on, or increased, by motion, extends 
along the back, and to the limbs, which are sometimes painful to the 



382 SUBACUTE SPINAL MENINGITIS. 

touch ; or it shoots round the abdomen or chest. There are contrac- 
tions of the back and neck, and of the limbs, varying with the seat of 
the disease, and assuming the form of trismus, torticollis, partial or 
complete opisthotonos, or general tetanic spasms. Sometimes there are 
convulsions, or choreic movements. There is a sense of constriction in 
the neck, abdomen, or chest, with urgent feelings of suffocation. In 
some cases the urine is retained and the bowels are confined. 

The disease generally proves fatal from the tenth to the fourteenth 
day, with delirium, coma, or typhous symptoms. 

Morbid Anatomy. — Inflammation of the arachnoid and pia mater, 
with effusion of serum beneath the arachnoid, or in the wide subarach- 
noid space between this membrane and the pia mater. In some cases 
inflammation and its consequences in the cord itself. 

Causes. — Those of inflammation of the substance of the cord. 

Diagnosis. — The rigid spasm or convulsions, and in many cases by 
the affection of the bladder, distinguish this disease. 

Prognosis. — Less unfavourable than when the substance of the 
spinal marrow is inflamed ; but attended with considerable danger. 

Treatment. — Leeches, and cupping to the part affected, followed 
by active aperients, a strict antiphlogistic diet, and perfect rest, in the 
recumbent posture. The state of the bladder should be ascertained, 
and the urine, if necessary, frequently drawn off. After the bleeding, 
bladders of ice may be applied with great advantage. Counter-irritants 
may be, at the same time, applied in the neighbourhood of the part. 
Benefit will also be derived from the use of mercury, so as to affect the 
system. In collapse, the strength must be supported by diffusible 
stimulants and injections. 

When the disease becomes chronic, and there is paraly>is with shaking 
or stiffness of the limbs, counter-irritation by issues, setons, and moxas 
may be practised with advantage. 

2. SUBACUTE SPINAL MENINGITIS SPINAL IRRITATION. 

Symptoms. — Pain in the affected portion of the spine, increased by 
firm pressure, percussion, or heat. Pain in the left side, or under the 
false ribs, or in all the muscles of the chest, or acute muscular pain 
over the whole of the abdomen. Dyspnoea and palpitation. Hysteria, 
depression of spirits, irritability, disordered bowels, constipation, flatu- 
lence. 

Sometimes these disorders, which are often of long continuance, are 
aggravated after marriage, but especially during lactation and preg- 
nancy ; the sufferer is constantly complaining of pains or unpleasant 
sensations of all parts below the affected vertebras. 

Diagnosis. — On making firm pressure with the index and middle 
finger of the right hand on the vertebrae from the neck to the lumbar 
region, or striking the several vertebrae successively, we discover one or 



RHEUMATIC SPINAL MENINGITIS. 3S3 

more painful points, and the pains in the side, chest, or abdomen are 
immediately increased ; or darting pains in those parts are produced, if 
they did not previously exist. In some instances these superficial pains 
are accompanied by convulsive movements of the muscles of the trunk. 

Causes. — Predisposing. The female sex. It is common in young 
females, and is sometimes associated with disorders of the spine. — 
Exciting. Sedentary pursuits, tight lacing, want of active exercise, 
constipation, painful menstruation, leucorrhcea ; the original cause and 
the effect continuing to react upon and increase each other. Spinal 
irritation may exist in other diseases, as in spasmodic asthma and 
chorea. 

Rationale. — The tender spine is the middle link between some 
remote irritation of the uterus or intestinal canal, and the pains in the 
muscles of the chest or abdomen. The irritation travels through the 
nerves of the part affected to the spine, where it first becomes sensible, 
and thence is reflected to the seat of pain. The connection of the 
muscular pain with the tender spine is evidenced by the effect of per- 
cussion in producing or increasing it ; also in exciting convulsions when 
these are combined with the pain. In the more severe cases of spinal 
irritation, which closely border on acute spinal meningitis, pressure on 
the spine causes both acute pain and violent convulsive or tetanic move- 
ments, and the slightest pressure on the site of the reflected pain will 
also cause convulsions. Pressure or percussion on other parts of the 
skin, or on the spine above or below the affected part of the cord, are 
not attended either by pain or convulsions. (G.) 

Prognosis. — Favourable. The disease generally yields to treat- 
ment ; but if neglected, it may assume the acute form, and so prove 
fatal. 

Treatment. — I. Local. The application of leeches or cupping- 
glasses to the tender part of the back, followed by blisters or stimulant 
liniments. Emplastrum belladonnas, or opii, will be needed in the 
relief of muscular pain. 

II. General. — Disorder of the menstrual function must be relieved 
or removed by appropriate treatment. The bowels must be carefully 
regulated, and tonics and sedatives, of which henbane is the most 
serviceable, judiciously employed. 

3. RHEUMATIC SPINAL MENINGITIS. 

Symptoms. — Diffused pain, often very acute, and accompanied by 
tenderness in the neighbourhood of the spine ; with severe neuralgic 
pain extending the whole length of one arm or leg, according as the 
disease attacks the lower cervical and upper dorsal vertebrae, or those 
of the loins. After a time the pain and tenderness become limited to a 
single spot near the spine, on one side, which is found on examination 
red and tender, and, after a while, may become the seat of an herpetic 
rash. The pain in the extremity continues, and is attended with numb- 



384 DISEASES OF THE SPIXAL CORD. 

ness and tingling of the fingers, with loss of power, or complete para- 
lysis. 

Pathology. — Rheumatic affection of the fibrous tissues of the 
spinal sheath, and of the tendons of the neighbouring muscles ; with 
cutaneous inflammation of limited extent. 

Causes. — Predisposing. Those of rheumatism and gout. — Exciting. 
Exposure to cold and wet. Fatigue. 

Diagnosis. — From muscular rheumatism by the local pain, and 
tenderness, and loss of power in the limb. 

Prognosis. — Favourable, but guarded. 

Treatment. — Leeches to the tender spot, followed by warm fo- 
mentations ; and the appropriate remedies for rheumatism. (See p. 353.) 



OTHER DISEASES OF THE SPIXAL CORD. 

Serous effusions occur within the spinal canal, as well as in the 
skull, and may be situate externally to the dura mater, or within it, or 
beneath the arachnoid membrane. 

Extravasation of blood may occupy the same situations. It may be 
caused by falls, blows, or slips, or by violent efforts, as pulling on 
boots, drawing a cork, or raising a heavy load. Effusions of blood 
(spinal apoplexy} have also been found in ca^es in which no accident 
had occurred. ; the symptoms being pain in the back, spasmodic contrac- 
tions of the muscles, paialysis of the bladder, rectum, and lower extre- 
mities, convulsions, or coma, and death. 

The membranes of the spinal cord may be thickened and indurated 
like those of the brain, and from the same causes ; and fungous growths 
form on the dura mater, causing pressure and paralysis. 

The cord may also become firmer than natural, after congestion or 
inflammation. It is subject, in common with the brain, to atrophy and 
hypei trophy, to tuberculous deposits, and carcinomatous degeneration, 
to hydatids and to aneurismal and other tumours. 

The diagnosis of all these affections is difficult and uncertain, the 
prognosis unfavourable, and the treatment chiefly palliative. When 
accompanied by inflammation, the treatment is that of Myelitis. 

The spinal marrow is also liable, like the brain, to concussion and 
compression, induced by external injuries, whether inflicted on the back 
or by falls on other parts of the body. In severe concussion, reflex 
motions of the limbs cannot be excited. The treatment is similar to 
that employed in the same diseases of the brain. 

A congenital malformation, known as Eydrorachis, or Spina bifida, 
consists in one or more fluid tumours on the lumbar, dorsal, or cervical 
vertebrae, communicating with the spinal canal. The tumour is variable 
in size, is often transparent, and the colour of the skin may be natural, 
reddish, or livid. If pressure be made on the tumour, it induces signs 



NERVOUS PAIX. 385 

of compression of the brain. The limbs are imperfectly developed, and 
the rectum and bladder are often paralysed. The skin may be absent, 
and in this case the tumour is covered by the dura mater, pia mater, 
and arachnoid membrane ; and the pia mater is congested and red. The 
spines, and usually the laminae, of the corresponding vertebras are 
wanting. In some cases the spines are separated along the median line, 
and are with the laminae widely divergent. Occasionally there is a 
division of the medulla, or it is entirely absent at the seat of the 
tumour. The cavity of the arachnoid contains a serous, transparent, 
sanguinolent or purulent fluid, which may communicate with the 
brain ; or be merely enclosed in the pia mater. 

Attempts have been made to treat these tumours by pressure, or by 
pressure with repeated tappings with a fine needle ; but both plans have 
proved ineffectual. When the integuments are wanting, or very thin, 
the tumours should be protected by a shield. 



DISORDERS OF THE NERVES OF SENSATION. 

Neuralgia Nervous pain. 

Neuralgia Faciei ... Tic Doloreux. 

Neuralgia Hysterica . Hysterical pain. 

Hemicraxia (See Cephalagia, p. 362.) 

Sciatica Pain in the sciatic nerve. 

Anaesthesia Loss of sensation. 

NEURALGIA— NERVOUS PAIN. 

Pain is a symptom of almost all acute, and many chronic, diseases,, 
When it is a distinct affection of the nerves themselves, it is termed 
neuralgia. It has its seat in the nerves of common sensation, but may 
affect those of organic life. 

Neuralgia may arise from many causes. It is a common consequence 
of debility following prolonged lactation, long-continued and excessive 
discharges, or exhaustion from loss of blood. When confined to one side 
of the head and face, and intermittent, it may often be traced to the 
same cause as ague. In many instances, pain is due to some remote 
irritation, and is termed sympathetic. Pain in the shoulder, in affections 
of the liver, and pains in the upper arm in certain cases of diseased 
heart, are examples of this variety. Here there is a well-known 
connection between the nerves supplying the disease! organ and those 
going to the seat of pain. In other instances of sympathetic neuralgia 
no such connection exists. Thus, common tic doloreux has been traced 
to acidity of the stomach, to an overloaded state of the intestines, or to 
diseased kidney. Another class of cases may be traced to pressure or 
irritation at the root of a nerve. A spicula of bone, or fragment of a 
foreign body, irritating the nervous trunk, is a common cause of severe 
and inveterate forms of neuralgia. Pain in the glans penis, from stone 
in the bladder, pain of the thigh and testicle from irritation of the 

2 C 



386 NEURALGIA FACIEI. 

kidney, pain in the back of the thigh and leg, and at the verge of the 
anus, from constipation, and distension of the hollow viscera by gas, 
as in colic, and in severe flatulence, are examples of neuralgia from 
pressure, or direct irritation. Another interesting and important class 
of pains are reflected pains, generally situated in the parietes of the 
chest or abdomen, and very frequently in the left side. (See p. 356.) 
Pains of the internal viscera, without symptoms of inflammation, form 
another class of neuralgic affections. Intense neuralgia of an intercostal 
nerve generally precedes or accompanies herpetic eruption of the side. 
Gastrodynia, enterodynia, and hysteralgia, are examples of pain in the 
organic nerves of the stomach, intestines, and uterus. Wandering pains 
in the muscles are common in aged persons, and in younger men through 
hard work, or after severe illnesses. Inflammation of the neurilemma, 
another cause of neuralgia, combines heightened sensibility with pres- 
sure. In most cases, no change of structure can be detected in the nerve 
itself. 



NEURALGIA FACIEI— TIG DOLOREUX. 

Definition. — Pain, with intervals of perfect ease, in some or all of 
the branches of the sensitive portion of the fifth or trifacial nerve. 

Symptoms. — The disease usually occurs in the middle-aged of both 
sexes. The pain is most acute, comes on at variable intervals, suffers 
considerable abatement, or entirely disappears without assignable cause 
for days, weeks, months, or even years together. It is at first confined 
to a limited spot, the supra-orbital, the infra-orbital, or the mental 
foramina, its most frequent seat being the right infra-orbital nerve. It 
is of the acute lancinating kind, compared to electric shocks ; or it is a 
severe burning sensation. Sometimes pain is the only symptom, but 
generally there is some redness, heat, and swelling of the part affected. 
If the eye be affected, there is a large secretion of tears ; if the mouth or 
jaw, a copious flow of saliva. After it has continued some time, it 
is apt to involve other branches of the nerve first affected. Thus, if it 
begin beneath the orbit, it spreads to the upper lip, and thence to the 
upper and lower jaw ; and it may mount over the orbit, extend over 
the entire scalp, and even for some distance down the spine. The 
general health is very little affected ; the patient, in spite of the most 
intense suffering, recovers his flesh and healthy aspect in a few days of 
intermission, and often attains a very advanced age. 

Causes. — Predisposing. The female sex ; pregnancy ; the nervous 
temperament ; anaemia ; debility ; fear, grief, or anxiety. — Exciting. 
Irritation of the root of the nerve within the cranium, or of one of its 
branches, from inflammation of the peridental membrane, or a carious 
tooth ; or from pressure in the bony canal in which the branch lies. 
Rheumatic affection of the nerve. 

Diagnosis. — From hemicrania, and brovj ague, by the seat and 
character of the pain. 



NEURALGIA HYSTERICA. 387 

Treatment. — We must first determine, whether the pain be due to 
local irritation. The sensitive branches of the trifacial nerve are 
peculiar in passing through long bony canals, and in being distributed 
to the teeth. Hence we must look for pressure, for inflammation of 
the peridential membrane, and for caries of the teeth. Stumps and 
carious teeth should be removed. If the pain be due to rheumatic 
affection of the sheath of the nerve, or of the periosteum lining the 
bony canals in which its branches run, it may be expected to yield to 
the appropriate remedies. 

If the irritation be reflexed from the stomach, bowels, or kidneys, we 
must apply remedies for indigestion, constipation, and the renal affection. 

In the ansemic condition, quinine and iron, alone or in combination, 
are generally successful. The best way of administering the quinine is 
in full and occasional doses. The most suitable form of iron is the sac- 
charated carbonate and the peroxide ; they may be given in doses of 
gr. xxx to 1 twice or thrice a day. 

Hydrochlorate of ammonia in doses of 30 grains thrice a day is oc- 
casionally successful, especially when the pain is confined to the jaws. 

The following local applications may be required in addition to the 
constitutiona] treatment: — 1. The inhalation of a little chloroform. 
2. Linimentum chloroformi, linimentum belladonnas, or a mixture of 
equal parts of chloroform and laudanum, may be rubbed into the gums, 
or over the painful nerve. Yeratria and aconitia ointments are often 
very serviceable. 

In a case of tic doloreux of many years' standing, which had spread 
from the right infra-orbital nerve to the upper and lower jaw, over the 
scalp and down the spine, accompanied by excruciating suffering, after 
tonics and narcotics, bleeding, blistering, and salivation, had been tried 
in vain, and nothing afforded any relief; a stream of cold water poured 
upon the forehead, and allowed to trickle over the face and neck, pro- 
cured refreshing sleep after the lapse of about five minutes, had the 
same effect on a repetition, was followed by the first good night the 
patient had had for weeks, and by a long interval of comparative 
ease. In this case the paroxysms were always accompanied with deter- 
mination of blood to the parts affected, and increased heat of surface. 
Where these characters are absent, cold may be expected to prove less 
efficacious. This patient died astatis 76, having been a great sufferer 
for at least 25 years. (G.) 



NEURALGIA HYSTERICA— HYSTERICAL PAIN. 

JMany women of hysterical temperament are subject to severe neu- 
ralgia. It may affect any part of the body. Occasionally it has its 
seat in a particular joint or bone. There may be no evidence of local or 
constitutional disease. The pain appears in many cases to be purely 
imaginary ; in all it is more or less superficial, and is absent or di- 
minished when the patient's attention is diverted from it. Rough 



388 SCIATICA. 

handling gives no more pain than the slightest touch, but of the reality 
and occasional severity of the disease there can be no doubt. E. G., 
a healthy unmarried woman of about forty years of age, complained of 
intense and constant pain in one knee ; there was no evidence of the 
least disease. Every kind of counter-irritation and constitutional treat- 
ment was adopted. After repeated treatment as an in-patient in the 
infirmary, the surgeon at last yielded to her importunities, and am- 
putated the leg. The knee-joint was perfectly healthy, and no disease 
of its nerves could be detected. Two years afterwards, she came again 
under treatment for similar pain in her other knee. She entreated the 
surgeons one after another to amputate this leg also, but they did not 
yield a second time to her solicitations. 

In another case the pain was limited to a small spot in the front of 
the tibia ; the pain was so acute that the surgeon supposed there was 
an abscess in the bone, and trephined, but no disease was met with. 
Soon after the operation the pain returned in the part, and continued 
for more than a year, at the end of which time the surgeon yielded to 
her wish, and amputated the leg. No cause for the pain could be de- 
tected. These cases show that the pain, originating, perhaps, in some 
trifling or even imaginary disorder of sensation, eventually becomes real 
and severe ; and they serve, at the same time, to remind us that there 
are certain affections of the nervous system, of the causes of which we 
are as yet ignorant. The shower-bath as a constitutional remedy, and 
the light application of the actual cautery in lines to the affected part, 
are the most hopeful means of relief. 



SCIATICA. 



Symptoms. — Acute aching or darting pain along the course of the 
sciatic nerve from the nates to the knee, or even to the ankle ; gene- 
rally increased by firm pressure in the track of the nerve. 

Causes. — The pressure of accumulated faces, or of tumours on the 
nerve. Syphilitic or rheumatic affection of its sheath. 

Diagnosis. — From muscular rheumatism by the pain being limited 
to the course of the nerve, and being little, if at all, affected by the 
motion of the limb. In sciatica dependent on constipation, the pain is 
generally increased by eveiy effort to relieve the bowels, 

Treatment. — The warm or vapour bath. Friction. Aperient 
medicines so administered as to keep the bowels free. The general and 
local remedies recommended in neuralgia faciei. 

I have seen several cases unrelieved by the remedies usually given in 
neuralgia, speedily cured by a few doses of compound colocynth pill, 
followed by black draughts. (G.) 



ANESTHESIA FACIEI. 389 



ANESTHESIA— LOSS OF SENSATION. 

Varieties. — Ancesthesia, paralysis of the nerves of sensation ; 
amaurosis, of the retina ; cophosis, of the auditory nerves ; anosmia, 
of the olfactory nerves ; ageustia, of the gustatory nerves. 

Ancesthesia, or loss of common sensation, may occur separately or 
with palsy of the voluntary muscles; it maybe general or partial, 
affecting one side or both. Facial anaesthesia is a well-known form of 
this disease. Numbness, in the hands and forearms, is not an unfrequent 
symptom in Mimosis inquieta. (See p. 264.) 

The treatment must entirely depend on the pathological condition 
by which the disease is induced — if by pressure, the cause must, if 
possible, be removed; if by deficient supply of blood, stimulants must 
be resorted to ; if by cold, the circulation must be restored. In other 
cases the treatment will be that of the diseased conditions with which 
it is associated. It is rare as a separate malady. 



ANAESTHESIA FACIEI. 



Symptoms. — Numbness or total loss of sensation in the forehead, 
cheek, nose, and chin, on one side of the face ; also in the lips, tongue, 
inside of the mouth and nose, and surface of the eyeball, generally 
accompanied by paralysis of the temporal and m asset er muscles on the 
same side. This loss of sensibility is sometimes attended by intense 
pain of the parts affected. 

Terminations. — In some cases ulceration of the cornea and de- 
struction of the globe of the eye. 

Pathology. — Injury to the fifth pair of nerves by disease, com- 
pression, or mechanical injury. 

Prognosis. — Favourable, in the absence of anaesthesia or palsy of 
other parts. U?ifar our able, if complicated with disordered functions 
of other cerebral nerves, or with symptoms of disease of the brain. 

Treatment. — Local depletion by cupping or leeches to the temples, 
followed by fomentations. The internal use of mercury, so as slightly 
to affect the gums. If the disease, in spite of this treatment, become 
chronic, small blisters in front of the ear, kept open by savin ointment. 



390 HEMIPLEGIA. 



DISEASES AFFECTING THE NERVES OF VOLUNTARY 
MOTION. 

Paralysis. Paralysis Agitans. 

Facial Palsy. Epilepsia. 

Lead Palsy. Catalepsia. 
Paralysis of the Insane. Chorea. 

Wasting Palsy. Tetanus. 

Locomotor Ataxy. Hysteria. 

Tremor aIercurialis. Hydrophobia. 

PARALYSIS— PALSY. 

Paralysis, although only a symptom of disease, may, like dropsy, be 
conveniently considered under a distinct head. 

Varieties. — 1. Hemiplegia; 2. Paraplegia; 3. General Paralysis; 
4. Partial Paralysis (including Paralysis of the Facial Nerve, Ptosis, 
&c.) ; 5. Lead Palsy; 6. Paralysis of the Insane ; 7. Wasting Palsy. 

1. HEMIPLEGIA. 

Defixitiox. — Loss of motion, or of motion and sensation, of one 
lateral half of the body. 

Varieties. — The late Dr. Todd distinguished five varieties of 
hemiplegia, viz., Cerebral, Spinal, Epileptic, Choreic, Hysterical, and 
Peripheral. 

Symptoms. — In cerebral hemiplegia, the limbs of the affected side, 
if raised, fall by their own weight ; the face on the same side is relaxed 
and void of expi ession, and drawn to the sound side ; the tongue 
deviates towards the palsied side; the speech is either lost, or it is 
thick, muttering, and unintelligible. In rare instances, the mouth is 
drawn to the affected side, and the tongue protruded towards the sound 
side. Digestion is more or less imperfect. The loss of power is gene- 
rally accompanied by anaesthesia, but in a few instances with hyperes- 
thesia : the temperature of the affected side is generally diminished, but 
occasionally elevated. The mental faculties are sometimes unimpaired ; 
but they frequently suffer, as shown by impaired memory, confusion of 
thought, inattention, irritability of temper, and depression of spirits. 
The pulse is often infrequent, but sometimes accelerated : the respiration 
is slow. The bowels are generally inactive. If the patient do not 
speedily recover, the palsied limbs shrink and grow cold. When the 
disease is partial, the arm is more commonly affected than the leg. If 
the power of the limbs be impaired, but not lost, the ami will be 
raised with difficulty, and often not without the assistance of the other, 
the hand cannot grasp firmly, the leg will be dragged after the sound 
limb, and in walking the patient will be very liable to trip. In cases 



HEMIPLEGIA. 391 

of recovery the leg regains its power first ; so that the patient can walk 
about, while the upper extremity still remains palsied ; but to this rule 
there are many exceptions. 

Hemiplegia is most common on the left side. It usually occurs 
suddenly, constituting the " paralytic stroke." 

Spinal hemiplegia. — In this very rare form the face and intellect 
are unaffected. 

Epileptic hemiplegia. — After an epileptic fit, the limbs of one side 
occasionally remain paralysed for a few minutes to a few hours, or for 
three or four days, or even much longer. Eecovery takes place before 
the next attack. 

Choreic hemiplegia sometimes occurs on that side of the body which 
is most affected by the choreic movements. 

In Hysterical hemiplegia the palsy is incomplete, and limited to an 
arm or a leg. In walking the leg is dragged along the ground. 

Peripheral hemiplegia. — Dr. Todd has given this term to those 
partial paralytic affections which commence with sensations of " needles 
and pins" in the fingers or toes, and gradually creep upwards, and 
more or less completely involve the extremities. The affection is occa- 
sionally paraplegic. This is the. Creeping palsy of Dr. Cheyne. 

Causes. — Sudden and complete hemiplegia, or the " paralytic 
stroke/' is invariably caused by an apoplectic seizure. Whenever the 
right corpus striatum, or any part of the motor tract intervening 
between it and the medulla oblongata, is ploughed up by sanguineous 
effusion, or subjected to pressure from effusions or tumours in its 
neighbourhood, complete hemiplegia of the left side of the body must 
of necessity result. If the disease come on slowly, it is the result 
either of a growing tumour or of softening of the nerve tissue. In the 
latter case, it is possible that a weakness and numbness of the one side 
of the body may suddenly lapse into a complete hemiplegia fiom sudden 
lesion of the softened fibres without haemorrhage. 

Incomplete hemiplegia is the result of pressure or lesion of one side 
of the spinal cord, immediately below the decussation of the antero- 
lateral columns. The paralysis of motion is on the same side as the 
lesion, the paialysis of sensation on the opposite side. 

Diagnosis. — Even in mild cases, cerebral hemiplegia is always asso- 
ciated with more or less paialysis of the face and tongue. In more 
severe cases the intellect is disturbed, speech is imperfect or obsolete, 
deglutition is more or less difficult. 

In spinal hemiplegia, the head, face, and tongue are unaffected, and 
sensation is impaired on the opposite side to the paralysis of motion. 

Epileptic hemiplegia is of cerebral origin, and may be known by the 
history of the case. 

Choreic hemiplegia is usually associated with some slight jerking 
movements of the paralysed limbs ; the face is unaffected ; the tongue 



392 PARAPLEGIA. 

does not deviate, and is usually protruded and withdrawn in a charac- 
teristic manner. 

Hysterical hemiplegia is known from choreic, by the presence of 
hysterical symptoms, or their previous existence. 

Prognosis. — Favourable. Youth ; a recent, partial, and incomplete 
attack, without cerebral symptoms ; a return of sensation, tiagling, 
and increased temperature. — Unfavourable. In proportion to the age, 
the duration of the disease, and the degree of paralysis. 

With a view to more correct diagno>is and prognosis, the late Dr. 
Todd arranged cases of cerebral hemiplegia into three classes. — 1. Those 
in which the muscles of the paralysed limbs are completely relaxed, the 
limbs being loose and flaccid, and the muscles wasted. — 2. Those in 
which the paralysed muscles exhibit a certain amount of rigidity from 
the moment of the attack or soon after. The muscles retain their 
plumpness and the limbs resist extension. — 3. The cases in which the 
wasted and relaxed muscles acquire, after some time, more or less ten- 
sion, becoming shortened and feeling like tight cords. From these 
various states of the muscles he has drawn inferences as to the nature 
of the lesion. The phenomena presented by the first class result, he 
considers, from white softening of the brain. Those of the second 
class are caused by irritation of healthy brain tissue in the neighbour- 
hood of the clot at the time of its formation, and subsequently during 
its absorption and the contraction of the wound. The muscular 
phenomena of the third class result from lesion of softened nerve-fibres, 
with or without the formation of a clot, the late rigidity resulting from 
the irritation caused by slow cicatrization of the wound, the process 
being attended by a dragging upon the healthy brain substance in its 
neighbourhood, and the irritation thus set up being conveyed to the 
muscles, results in gradual contraction. 



2. PARAPLEGIA. 



Definition. — Loss of motion, with more or less impairment of 
sensation of both sides of the body. Only the lower half of the body 
may be affected ; or the whole of it except the head ; or the head not 
excepted, coupled with complete insensibility (coma). 

The term paiaplegia is usually limited to paralysis of the lower half 
of the body, but we here give it its unrestricted signification. 

Varieties. — 1. Organic, functional, or reflex. 2. From constitu- 
tional disorder. 

Symptoms. — Like other forms of paralysis, organic paraplegia may 
occur either suddenly or gradually. Sometimes it is complicated with 
head symptoms, but more fiequently these are absent. The extent of 
the paralysis will depend on the seat of the lesion. (See p. 368.) When 
the disease affects the lower part of the cord, and the paralysis is com- 
plete, there is entire loss of sensibility and motion in the lower extre- 



PAKAPLEGIA. 393 

mities, with palsy of the bladder and rectum. The patient being 
confined to the horizontal position, the back and sacrum are apt to 
slough. The retained urine is generally highly ammoniacal, and ulti- 
mately becomes bloody. It is prone to form calculous deposits. 

In less complete forms of paraplegia, there is weakness of the legs, 
with a sensation of stiffness and heaviness, numbness, tingling, or formi- 
cation, and an awkward, straggling, tottering gait. These symptoms 
gradually increase till perfect paraplegia, with paralysis of the bladder 
and rectum, results. In many cases the disease does not prove fatal till 
it has involved the arms and chest and the muscles of respiration. If 
the disease extend still higher into the cervical region, the roots of the 
phrenic nerve become involved, and life then necessarily ceases. In 
many cases of paraplegia, and especially in the more complete forms, the 
reflex function remains intact, and irritation of the sole of the foot 
occasions involuntary contractions of the muscles. Sometimes these 
reflex movements are very troublesome, the limbs being affected for 
many hours together with clonic spasms. In the paraplegia resulting 
from spinal concussion 1 eflex movements are absent. 

Causes. — Injuries to the spinal cord. Chronic disease of the cord or 
of its membranes ; increasing pressure from growing curvature of the 
spine ; caries of the vertebrae and relaxation of the spinal ligaments ; 
pressure on the descending aorta. 

Functional paraplegia has many causes, amongst which the most 
common are intense cold, excessive sexual intercourse, masturbation, and 
the syphilitic poison — a frequent cause of organic disease. Many cases 
of incomplete paraplegia have been referred to nervous action, and have 
been teimed accordingly " Reflex paraplegia" or " reflex paralysis." 
Gonorrhoea, stricture of the urethra, nephritis, cystitis, uterine diseases 
and displacements, dysentery, dentition, and even irritation of the 
cutaneous nerves, have been advanced by various authors as causes of 
reflex paiaplegia. The paralysis is supposed to be due, in such cases, to 
the arrest of the circulation in the spinal cord, from contraction of its 
blood-vessels, the contraction being produced by an irritation trans- 
mitted from the nerves of the diseased or irritated surface to the nerves 
of the blood-vessels distributed to the cord. The arguments in favour 
of such a theory are as follows : — 1. Dr. Brown Sequard noticed contrac- 
tion of the vessels of the pia mater of the cord on applying a ligature to 
the hilus of the kidney, or to the blood-vessels and nerves of the supra- 
renal capsules. 2. Violent rigors and even convulsions (affections gene- 
rally recognised as due to reflex irritation) occasionally attend cathe- 
terism or dilation of the cervix uteri. 3. The absence of anatomical 
lesions of the cord in such cases of functional paraplegia as have been 
examined. 

Prognosis. — Favourable, in cases of functional disorder ; but highly 
unfavourable in cases of actual disease of the spinal cord or brain. In 
the most favourable class of cases recovery is generally slow, occupying 
weeks or months; and, in unfavourable cases, the pat ; ent may linger 
for years. 



394 PARAPLEGIA. 

Treatment. — The indications are: I. The use of remedies appro- 
priate to the diseased condition on which the palsy depends. II. The 
use of remedies calculated to act directly on the parts affected ; and, 
III. The relief of incidental symptoms. 

I. For the first indication, see Apoplexy, Myelitis, Spinal Arachnitis, 
and other diseased conditions of the brain and spinal marrow. 

When the disease has become chronic, and all inflammatory symp- 
toms have disappeared, we may resort to the astringent chalybeate 
tonics, such as the perchloride of iron ; to the mineral acids ; to 
quinine when the system will bear it. In paralysis from cerebral 
apoplexy we must intermit its use ; if it produces headache, and heat 
of head, &c., Strychnia, in doses of ^ to the ^ of a grain, two or three 
times a day, cautiously increased, may be given with advantage. Its 
action on the system is indicated by twitchings of the paralysed 
muscles, but these taken as indications of returning power are delusive, 
as they depend on an affection of the excitomotory nerves. The same 
remedy may be applied locally, J of a grain being sprinkled on a blis- 
tered surface, near the origin of the paralysis. Tincture of cantharides 
(Form. 23) is useful in some cases of paraplegia, especially in that 
form which depends on disease of the urinary organs. It stimulates 
the bladder to more healthy action, and in cases dependent on effusion 
into the sheath of the spinal marrow, may act favourably as a diuretic. 
Oil of turpentine, in drachm doses, suspended in mucilage, may also be 
given with advantage in the same cases in which cantharides is beneficial. 

Paralysis from constitutional disease or reflex action must be treated 
according to the cause. (See Syphilis, Hysteria, &c.) 

II. This indication is fulfilled by friction with the flesh-brush, or 
stimulating liniments; by blisters; the actual cautery; electricity. 
To apply electricity we must include the part we wish to operate 
upon between the two conducting wires of the battery, one wire or 
electrode being placed on the affected part, and the other upon the 
nerve-centre or nerve-trunk corresponding to the affected organ. The 
muscles are excited through the skin. Electricity may be applied in 
the following modes : — 1. By the electric hand. One electrode consists 
of a moistened sponge, inclosed in a metallic cylinder, and this is 
placed upon a point of surface which is not very excitable ; the ope- 
rator holds the other electrode in one of his hands, and then rapidly 
passes the back of the other over the parts he wishes to excite, after 
having dried the skin of the patient with starch, or lycopodium. — 

2. By including the part to be excited between two electrodes composed 
of sponge soaked in salt and water, and inclosed in metallic cylinders. — 

3. By including the part between two solid metallic electrodes, cylin- 
drical or conical, and moving them rapidly over the affected parts. — 4. By 
the electric brush ; the moist sponges being replaced by a brush of fine 
metallic wires. — 5. By placing the two hands or two feet each into a 
basin of water, and plunging into each vessel one of the electrodes of the 
battery. It will be obvious that the nervous centres must be stimu- 
lated in this last process. The magneto-electric battery is the most 
appropriate kind for generating currents for medical purposes. 



PARTIAL PARALYSIS. 395 

In using electricity, we must bear in mind the fact that, when the 
current is intense, and its action prolonged in the same direction, the 
excitability of the nerves of the part is much enfeebled. When, there- 
fore, we wish to increase the vitality of the nerves, we should use only 
feeble currents, guided alternately in opposite directions. But, at 
the same time, the velocity of the intermittenc : es should always be 
great, because by this means the contraction of the muscle is main- 
tained, and its force at the same time increased. We are thus enabled 
to imitate the voluntary motions. Slow intermittencies only produce 
trembling. In anaesthesia, the most intense currents are powerless in 
rousing sensibility if they do not succeed each other with great rapidity. 
In the treatment of muscular atrophy, we must also use currents with 
rapid intermittencies. The rapidity of the intermittencies is in direct 
proportion to the number of the rotations of the armature in front of 
the magnet. 

The cases of paralysis in which electricity is beneficial, are those 
resulting from apoplexy of the brain or cord ; but on no account must 
it be used till all irritation has ceased in these nervous centres — until, 
in fact, the clot has been absorbed and cicatrization effected. The 
absence of pain, and a lax condition of the paralysed muscles, will be 
our best indications that these have been effected. 

In addition to electricity, we may use salt-water baths, shampooing, 
the warm or hot-water douche, and, when the power of the extremities 
has in some degree returned, exercise. These remedies also are inap- 
plicable in the early stage of the paralysis which depends on acute 
disease of the brain or spinal cord. They should not be resorted to till 
inflammation has ceased, and the disease has become chronic. 

III. When the bladder and rectum are involved, the catheter should 
be used at least once a day ; and if the urine become ammoniacal or 
bloody, the bladder should be washed out with warm water after the 
use of the catheter. Bed-sores must be carefully prevented by the 
use of the water-bed, and by rigid attention to personal cleanliness. 



3. PARTIAL PARALYSIS. 

Particular muscles or groups of muscles are subject to paralysis 
from injury of the root of the trunk of the nerves distributed to them. 
The muscles of expression are very liable to this affection. Injury or 
disease of the motor portion of the fifth nerve, gives rise to a less 
common form of partial paralysis. Strabismus may be caused by palsy 
of one or more of the muscles of the eye. The paralysis of the superior 
branch of the third or motor oculi nerve occasions falling of the upper 
eyelid and closure of the eye (jrtosis) ; and disease of the facial nerve 
entails, as one of its consequences, an open state of the eye due to 
paralysis of the orbicularis palpebrarum {lagopMhalmid) ; paralysis of 
the laryngeal nerves occasions aphonia ; and paralysis of the hypo- 
glossal nerve, loss of speech. 



( 396 ) 



Paralysis of the Face. 






The motor nerves of the face being the portio dura, and the lesser 
root and third division of the fifth, and the sens itive nerves the first and 
second divisions, with the ganglionic portion of the third division, of the 
fifth nerve, it is easy to trace facial paralysis to its source. In perfect 
paralysis of the face, the portio dura and motor branch of the third 
division of the fifth suffer jointly : when the latter only is affected, the 
motions of the jaw on that side are paralysed, and in this case there is 
usually some loss of sensibility ; but as the disease is confined to the 
muscles employed in mastication, there is no distortion of feature, 
beyond a flattening of the affected side of the lower jaw, and of the 
temple. 

Symptoms. — In palsy of the muscles supplied by the facial nerve, 
the expression is very characteristic. The features are drawn to the 
sound side, so that it appears shorter and narrower than the paralysed 
side. The two sides of the face wear so different an expression that the 
patient is said to laugh on one side and cry on the other. He is unable 
to frown on the affected side, and when desired to shut the eyes, the eye 
of the sound side is firmly closed, while that on the palsied side is either 
partially closed or remains wide open, the pupil, at the same time, 
being rotated upwards or inwards. In sniffing, the nostril of the affected 
side collapses ; in blowing, the air escapes from the paralysed side. 
The saliva dribbles from the palsied side, and the food either slips from 
the mouth, or collects between the teeth and palsied cheek, which is 
_ often bitten. The power of 

whistling is also lost, and 
when the patient speaks, 
laughs, cries, sneezes, or 
coughs, the deformity is in- 
creased, the paralysed side 
remaining motionless, while 
the sound side is strongly 
contracted. The cheek on 
the affected side is flaccid, 
and swells during strong ex- 
piration. The labial con- 
sonants, 6, p, and /, are im- 
perfectly sounded; but the 
patient can speak distinctly 
w T hen the lower lip on the 
affected side is supported by 
the finger. The sensation 
of the affected side is gene- 
rally unimpaired. 
J The above woodcut (Fig. 

50) shows the expression of the face in a patient of King's College 
Hospital, suffering from this disease. The right side is the seat of 




PARALYSIS OF THE FACE. 



397 



the paralysis; and the two sides present the striking contrast just 
described, the light having a sad, and the left a merry, expression— a 
difference readily perceived 



Fig. 51. 




by covering one side of the 
face and then the other. 

The second woodcut (Fig. 
51) is taken from a sketch 
of another patient of King's 
College Hospital. It shows 
the expression of the face 
when a patient so affected is 
desired to shut the eyes. In 
this instance the left side is 
the seat of the disease j and 
the eye of that side cannot 
be closed, while the right 
eye is firmly shut. The 
whole face is drawn forcibly 
to the sound side, and all 
the features of that side are 
strongly contracted. 

Fig. 52 exhibits paralysis 
of the left facial nerve in 
a child, with nability to close the left eye. 

These illustrations of paralysis of the facial nerve may be advan- 
tageously compared with the 

woodcut (Fig. 53), which Fig. 52. 

shows the state of the face 
in a well-marked case of 
hemiplegia affecting the left 
side. The eyelids of the 
paralytic side are closed, 
though less firmly than 
those of the sound side, while 
the features of the two sides 
present the same contrast, 
though in a less degree, than 
in Figures 50 and 51. 
(Figures 52 and 53 are 
taken from Marshall Hall's 
Principles of Medicine.) 

Diagnosis. — In paralysis of the facial nerve alone there is an absence 
of cerebral symptoms ; the face retains its sensibility ,* the function of 
hearing is intact ; the pupil is unaltered, and the eyesight unaffected (ex- 
cept as the result of the open state of the eye) ; the muscles of mastica- 
tion retain their power ; the speech is only affected as above stated, and 
is distinct when the paralysed lip is supported by the finger. Complica- 
tion with deafness would show that the other division of the seventh 




39S 



PAEALYSIS OF THE FACE. 




nerve was affected; the addition of anaesthesia that the fifth nerve 
was also implicated ; and cerebral symptoms would indicate that 

the seat of the disease 
Fig. 52. affecting the neives was 

within the skull and not ex- 
ternal to it. Hemiplegic 
paralysis is known by dis- 
order of innervation in the 
limbs. 

Ptosis, or closure of the 
eye from palsy of the supe- 
rior branch of the third 
nerve, is regarded as a more 
serious disease than palsy of 
the facial nerve, being more 
probably due to intercranial 
disease. 

Prognosis . — Favour- 
able. When the paralysis 
does not extend beyond the 
parts supplied by the facial 
nerve. The disease is often cured in about three weeks or a month. — 
Unfavourable. Complication with paralysis of other nerves, or with 
disease of the brain. 

Sequela?. — Inflammation of the conjunctiva, and in rare cases, ulcera- 
tion of the cornea, and destruction of the eye of the affected side. 

Causes. — Tumours within the cranium, or disease involving the 
root of the nerve ; but intercranial disease is very rarely indicated by 
facial paralysis alone ; deafness on the same side is, at least, a ne- 
cessary concomitant of internal disease. Wounds and mechanical in- 
juries. Disease of the petrous portion of the temporal bone in the 
vicinity of the tympanum. The caries resulting from scarlet fever 
often erodes the wall of the Fallopian canal, and the nerve, being laid 
bare, is involved in the disease and loses its function. The piessure of 
tumours, especially of the parotids; effusions into and around the 
sheath of the nerve. Cold. 

Treatment. — If intercranial disease be the cause of the palsy, and 
febrile symptoms be present, cupping or leeches behind the ear, followed 
by a blister to the same part. Iodine and mercury. 

Parotitis must be treated as recommended under that affection. 
Caries of the internal ear, by daily injections of waim water, followed 
by weak solution of sulphate of zinc, by tonics, and attention to the 
general health. 



( 399 ) 



LEAD PALSY— DROPPED HAND. 

Sr:viPT03i3. — The hands are generally first affected, and in some cases 
the forearm also suffers. The di>ease begins by weakness in the fingers,, 
extending to the wrists, but rarely beyond them. There are at the same 
time shooting pains in the forearms, arms, and shoulders. The parts 
affected, after a time, waste from disuse, and the hands drop powerless 
at the wrists. The disease is generally preceded by one or more attacks 
of colic, but may occur independently of it. 

Diagnosis. — The history of the case. The seat of the palsy, assisted, 
in many cases, by the discovery of a blue line on the gums. 

Prognosis. — Favourable in first attacks and in slight cases. In 
some cases recovery after prolonged treatment. In others incurable. 

Causes. — The employments of the plumber and glazier, oil-painter, 
and enamel-card makers. Fishmongers who use lead counters, men 
employed in lead-works, and persons who drink cider made by presses 
repaired with sheet-lead. Water kept in new leaden cisterns, or con- 
ducted through leaden pipes, the danger being, as a general rule, in 
proportion to the purity of the water. 

Pathology. — The presence of lead in the blood and nerve tissue. 

Treatment. — This must be directed to two objects. I. To eliminate 
the poison from the system. II. To rouse the paralysed muscles to 
action. To attain the first object we may give iodide of potassium in 
five-grain doses. Sulphur baths (Form. 335), or in the form of vapour. 
The second object maybe attained by the use of electricity, shampooing, 
friction with the flesh brush, or with stimulating liniments ; and by 
the internal administration of strychnia (Form. 19). Electricity is a 
very valuable remedy in this disease ; the current should be a feeble one 
and the intermittencies very rapid. It should be passed in succession 
through individual muscles. 

Prophylaxis. — In lead- work, the use of a respirator of moist flannel. 
Scrupulous washing of the hands. 



4. PARALYSIS OF THE INSANE. 

This is a form of progressive paralysis attendant upon gradual loss 
of mental power. It first appears in the tongue, causing indistinct- 
ness in the speech and faulty or stammering pronunciation ; it affects 
the muscles of both sides of the face, impairing the power of expression, 
and thence extends to the whole of the muscular system. The com- 
mencing palsy of the legs is indicated by slight lameness and occasional 
tripping, and that of the arms by the frequent chopping of food and 
other objects from the hand. The progress of the disease is gradual, 



400 WASTING PALSY — TABES DORSALIS. 

but it terminates at length in complete paralysis, with palsy of the 
bladder and sphincter ani, of the muscles of deglutition, and of the 
respiratory muscles. The patient often dies asphyxiated. The sensi- 
bility is little impaired. The common duration of this malady is four 
or five years. The palsy of the muscles is accompanied by loss of 
mental power, the patient becomes imbecile. 

Diagnosis. — In the early stage, the youthful appearance caused by 
the relaxation of the wrinkles of the features ; and, in an advanced 
stage, the peculiarly vacant expression of the whole countenance and 
the wide open eye are very characteristic. In Sir Alexander Morison's 
work on Insanity, these changes of expression are well shown in the 
same patient in an early and advanced stage of the disease. 

Prognosis. — This form of disease is dependent on progressive soften- 
ing of the brain, and does not admit of cure. 

Treatment.— That of Cerebral Softening (see p. 378). 



5. WASTING PALSY 



Is a form of partial or general paralysis, slowly progressive, and 
invading particular groups of muscles, or the whole of the muscular 
system. The affected muscles slowly weaken and waste until they aie 
reduced to pale cords streaked with tat, or to mere bands or membranes 
composed chiefly of fibrous tissue. 

The muscles of the upper extremity appear to be most liable to the 
disease, and of these the muscles of the ball of the thumb are most 
commonly affected, and the hand is robbed of its muscular masses, and 
resembles the foot of a bird — the "main en griffe" of French writers. 
When the muscles of the face are affected, expression is lost, and^ but 
for the motion of the eyes, the countenance is as fixed as that of a 
statue. 

The brain is unaffected, and the general health good. The disease 
is often traceable to injury either of a particular nerve trunk or of the 
spinal cord itself. The anterior roots of the spinal nerves are often 
found to be atrophied. 

The only treatment likely to be of service is galvanism. 



6. LOCOMOTOR ATAXY— TABES DORSALIS. 

This and other names have been given to a derangement of the 
lower extremities not amounting to paralysis, but consisting of a want 
of co-ordinating power. The muscular contractions are still, to 
certain degree, obedient to the will, nor is there want of power ; but 
the movements are clumsy and uncertain, and the patient cannot walk 
steadily unless he looks at his legs in order apparently to guide their 



MEKCUEIAL TREMORS. 401 

movements. He has great difficulty in rising from his seat, and in 
turning round is apt to fall ; the gait is clumsy, hurried, and stagger- 
ing. The disease may affect the muscles of the upper extremities when 
the movements of the arms and hands become awkward and fumbling. 

Diminished sensation is a constant attendant upon this condition of 
the limbs, and is generally proportionate to the want of co-ordinating 
power. 

In some cases there are evidences of impairment of mental power, 
but usually the mind is clear ; and excepting slight defect of sight and 
hearing, the brain appears healthy. 

Dr. Todd attributed this condition to disease of the posterior columns 
of the cord, but the pathology is still very obscure. 

In the treatment some good may be expected from the judicious use 
of galvanism and alterative tonics. 



TREMOR MERCURIALIS— MERCURIAL TREMORS. 

Symptoms. — This disease usually shows itself first by weakness in 
the arms, which gradually increases. It is accompanied by slight con- 
vulsive twitehings, followed by tremors, increasing in violence till the 
patient is obliged to abandon his occupation. The trembling gradually 
extends to the lower extremities, and at length to the entire body. It 
is brought on by every attempt to move, but it ceases when the limbs 
are supported, and the body is at rest. The patient dances rather than 
walks ; he is unable to grasp objects ; his speech is hurried and abrupt, 
and in extreme cases he cannot even masticate. If the patient continue 
to expose himself to the poison, restlessness, sleeplessness, and delirium 
supervene. Salivation is only occasionally present. The general 
health is impaired, and there are nausea and anorexia, a dry skin and a 
furred tongue ; but there is no disorder of the circulation or respira- 
tion, and no colic. In very mild cases, especially when they occur in 
women, the symptoms are those of Mimosis Inquieta (see p. 264). 

Among the minor effects of working with mercury may be mentioned 
a peculiar brittle state of the teeth, causing them to chip constantly, 
and exposing them to early decay. 

Diagnosis. — From paralysis agitans, by the history of the case, 
and the absence of trembling when the limbs are supported. 

PROGNOSIS. — Favourable when the cause is excluded. 

Causes. — The process of water-gilding ; employment in quicksilver 
mines ; long exposure in any way to the fumes of mercury, or to the 
absorption of the oxide by the skin. 

Treatment. — A temporary cessation of employment ; a combina- 
tion of tonics and sedatives ; preparations of iron ; a generous diet, 
with a moderate allowance of wine ; the shower-bath. 

2 D 



402 PARALYSIS AGITAXS — EPILEPSIA. 

Prophylaxis. — Cleanliness and free ventilation of workshops. In 
those who inhale mercury, an arrangement by which the fumes can be 
carried off, such as a funnel terminating in a chimney ; eggs swallowed 
two or three times a day ; the free use of milk as an article of diet ; in 
those who handle mercury, the use of gloves. 



PARALYSIS AG1TAXS— SHAKING PALSY— THE TREMBLES. 

Symptoms. — Weakness and trembling, usually commencing in the 
hands and aims, but sometimes in the head, and gradually extending 
over the whole body. At length, the trembling becomes incessant ; 
and when the patient attempts to walk, " he is thrown on the toes 
and fore part of the feet, and impelled unwillingly to adopt a running 
pace, being in dangei- of falling on his face at every step." In a still 
more advanced stage, the shaking continues during sleep ; the patient 
cannot carry food to the mouth ; and mastication and deglutition are 
performed with difficulty. The agitation at length becomes so violent 
as to prevent sleep ; the body is bent forward, with the chin upon the 
sternum ; articulation is impaired or entirely lost ; the urine and faeces 
pass involuntarily, and coma and slight delirium close the scene. In 
some cases, the muscles of respiration are affected, and the breathing- 
becomes extremely frequent. (In one case occurring in a vigorous 
young man, 73 in the minute, with a pulse of 72. — G.) 

Diagnosis. — Tremor, and a shuffling, hurried gait. 

Prognosis. — Unfavourable in old persons. Less unfavourable 
when, as in rare instances, it occurs in persons in the vigour of life. 

Causes. — Predisposing. The male sex, advanced age. — Exciting. 
Violent exertion, mental or muscular ; cold ; rheumatism. 

Treatment. — In persons advanced in life, a combination of stimu- 
lants and sedatives is indicated. Conium and henbane are useful in 
the early stages ; preparations of iron and galvanism in the latter. 



EPILEPSIA— EPILEPSY. 
Synonym. — Falling sickness. 

Definition. — Fits recurring at irregular intervals, with sudden 
loss of sense and power of motion, frequently preceded by a shriek, 
attended by general convulsions, and usually followed by coma. 

Symptoms. — The patient is seized suddenly, or after a short warn- 
ing, with loss of consciousness and of power, so that, if he be standing, 
he suddenly falls, or is thrown to the ground. The fit, which is 



EPILEPSY. 403 

frequently preceded by a loud, piercing cry, consists in strong con- 
vulsive motions of the limbs and trunk, and various distortions of the 
countenance. The brows are knit ; the eyes fixed and staring, or 
turned up beneath the lids ; the pupils are dilated and do not contract 
when exposed to light. The hands are firmly clenched, and the arms 
are tossed about. The breathing becomes gasping and difficult, or is 
altogether suspended ; the heart beats violently ; the vessels of the 
head become turgid and the face is livid ; foam, often bloody, issues 
from the mouth ; the jaws are contracted with great force, so that the 
under lip, or the tongue if protruded, is apt to be severely injured. 
The faeces, urine, and semen are sometimes expelled, and priapism is 
not uncommon. After the convulsions have continued for a few 
minutes, they cease, leaving the patient motionless, but in a state of 
insensibility, and under the appearance of a profound sleep. He 
gradually recovers, and, if left to himself, will generally sleep for 
some hours. Sometimes there is a succession of fits, with intervals of 
torpor, lasting for several hours. 

There is a form of epilepsy, of frequent occurrence, called by the 
French petit mat, in contradistinction to the foregoing, which is de- 
signated the grand mat. It consists in sudden and transient giddiness 
with loss of consciousness, confusion or incoherence of mind, and un- 
steadiness of gait, accompanied in some instances by erections of the 
penis, in others by slight convulsions. Such slight fits are often fol- 
lowed by great confusion of intellect, and sometimes by maniacal incohe- 
rence. (In one case of epilepsy belonging to this class every fit of 
epilepsy was followed by an unconscious exposure of the person. — G.) 

Premonitory symptoms. — In some cases the fit is ushered in by pre- 
monitory symptoms, such as pain in the head ; lassitude ; bright 
circles of colours before the eyes, sudden flashes of light, in rare 
instances spectral illusions ; or there is a loud noise in the ears ; or an 
offensive smell ; or a bitter taste ; unquiet sleep ; unusual dread ; pal- 
pitation of the heart ; coldness of the joints ; fluttering at the epigas- 
trium ; vomiting ; a sensation of cold, or a pain arising in some part of 
the extremities, and gradually creeping upw T ards till it reaches the 
head (the aura epileptica\ when the patient is instantly deprived of 
sense, and falls as above described. (In a case that came under my 
notice, every fit was preceded by the utterance of the same incoherent 
sentence, to which the patient attached no meaning. — G.) But in the 
majority of cases, the fits are not preceded by any warning. They 
occur at very variable intervals ; sometimes in the day, sometimes at 
night, during sleep ; and there are often several fits in the twenty-four 
hours ; in other cases, there are intervals of months or years. 

Causes. — Predisposing. Epilepsy or insanity in parents or ances- 
tors ; scrofula ; malformation of the head ; the male sex ; debility in 
nervous persons; dissipation, intemperance, self-abuse, and excessive or 
suppressed discharges. — Exciting. Sudden fright ; fits of passion, or 
vehement emotions of the mind; sexual intercourse; masturbation; 
plethora of the vessels of the head ; anaemia of the brain and spinal 



404 EPILEPSY — TREATMENT. 

cord, such as occurs in cases of excessive uterine haemorrhage (epileptic 
convulsions terminate the lives of animals who are bled to death) ; 
reflex irritation from worms ; dentition ; acute pain ; excessive evacua- 
tions ; suppression of accustomed discharges, especially the urine and 
the bile ; tumours compressing the brain, or any part of the nervous 
system ; parasites in the brain (the caenurus cerebralis is the common 
cause of convulsions in sheep). Epilepsy sometimes occurs as a symptom 
of poisoning, especially in poisoning by arsenic and lead. 

Morbid Anatomy. — In most cases there is congestion of the 
vessels of the brain. In the remainder, such causes of irritation as 
thickening of the membranes, spiculae of bone, internal nodes, tumours, 

or the cystic form of taenia. 

Diagnosis. — From hysteria, by the total suspension of conscious- 
ness, the solitary cry, and the deep sleep which succeeds the fit. From 
feigned epilepsy, by the total insensibility, extending even to the retina. 
From apoplexy, by the transient nature of the fit, the absence of the 
stertorous breathing, and, in most cases, by the absence of paralysis, 
and the completeness and universality of the convulsions. From tetanus, 
by the insensibility, and the clonic character of the convulsion. 

Prognosis. — Favourable. When sympathetic, occurring before the 
age of puberty, and arising from exciting causes easy of removal; or 
originating in functional derangement of the uterine system. — Unfavour- 
able. When the disease comes on after puberty ; hereditary predispo- 
sition ; scrofulous diathesis; long previous continuance of the malady, 
and frequent occurrence of the fits ; misshapen skull ; the epileptic 
physiognomy ; impairment of memory and judgment. 

Treatment. — I. During the fit. II. During the interval. 

During the fit. — The patient should be placed, if possible, on a soft 
bed, the neckcloth and shirt-collar loosened, and the tongue protected by 
a piece of soft wood, or a pad of linen, placed between the teeth. When 
the fits occur duiing sleep, and the tongue is severely bitten or torn, 
the patient should wear a smooth rounded guard, fitting closely to the 
teeth, above and below. After the fit. the patient should be allowed 
to sleep; if much exhausted, he may take some slight stimulant. 

In the interval. — The recurrence of the fit is sometimes prevented — 

1. By removing all causes of irritation, as constipation, intestinal 
woims, the irritation of teething, &c. 

2. By avoiding the exciting causes, such as over- distension of the 
vessels of the head, however induced ; fits of passion, or other violent 
emotions of the mind ; intemperance, dissipation, or other bad habits. 

3. If the patient be plethoric, by occasional bleeding, abstemious diet, 
and saline aperients. Issues or setons in the neck or arm, or antimonial 
ointment rubbed into the spine, sometimes give relief. 

4. If the patient be weak and irritable, by tonics ; as quinine, sul- 
phate, oxide, and valerianate of zinc, sulphate and sesquioxide of iron, 
sulphate or ammonio-sulphate of copper, nitrate of silver (an objection- 



CATALEPSY. 405 

able remedy, because it sometimes causes permanent discoloration of the 
skin), and liq. arsenicalis. He should rise early, take regular exercise, 
nourishing but not stimulating diet, and use cold bathing, or the 
shower-bath. 

In females attention should be paid to the state of the uterine func- 
tion. Amenorrhcea ; amenorrhea with plethora; dysmenorrhcea ; leu- 
corrhcea or menorrhagia ; the nervous symptoms attendant on these 
conditions, and on the change of life, should receive early attention, 
according to the rules given for the treatment of these diseases. 

5. Bromide of potassium has been much used of late years, and, ac- 
cording to some observers, with marked success. Beginning with 5 or 
10 grains,the dose may be increased to 30 or 40 grains. 

6. If there be a syphilitic taint, mercury, or iodide of potassium. 

Remedies. — Immediately before the fit. Pressure on the carotids ; 
a ligature between the parts from which the aura first proceeds and 
the brain, as round the thumb or little finger when it begins there ; a 
strong mental effort ; violent exercise ; irritation of the nostrils, with 
snuff, or strong smelling-salts ; dashing cold water over the face and 
head ; an emetic ; a full dose of opium or laudanum. — In the intervals. 
Wormwood ; gratiola ; mug-wort ; narcotics and sedatives, as opium, 
lactuca, conium, stramonium, belladonna, and digitalis ; antispasmodics, 
as valerian, assafcetida, musk, and castor ; turpentine, indicated wherever 
worms are suspected to exist. Nux vomica and strychnia ; electric 
sparks drawn from the head. In cases preceded by the aura, division of 
the nerve running from the seat of the aura or amputation of the part, 
have been recommended, but they are of very doubtful efficacy. 



CATALEPSIA— CATALEPSY. 

Definition. — A sudden loss of consciousness with retention of the 
posture in which the patient happens to be at the moment of seizure. 

Symptoms. — Catalepsy is an extremely rare disease, allied to those 
of the present section. Its essential features are, a fixing of the body 
in the position in which it happens to be in at the moment of the seizure, 
or in which it may be placed during the fit, accompanied by total in- 
sensibility. The fit itself is rarely, if ever, fatal ; but the intellectual 
faculties seem to suffer by its frequent repetition. 

A lad of about fourteen years of age, a playmate of my own, was 
subject from childhood to this disease. He was often seized in the 
midst of his sports, without previous warning, and fixed like a statue in 
the attitude in which he happened to be at the moment. The fit rarely 
lasted more than one or two minutes, and when it ceased, he resumed 
his play with a slight air of surprise and embarrassment. He was found 
dead in a bath, into which he had fallen. (G.) 

The causes of this disease are obscure, and little is known of its 
appropriate treatment. The general principles on which it should be 



406 ST. VITUS'S DANCE. 






conducted are the same as those of epilepsy. Existing irritation must 
be removed, and any occasional determination of blood to the head must 
be removed by appiopriate lemedies. 



CHOREA SAXCTI V1TI— ST. VITUS'S DANCE. 

Definition. — Functional derangement of the motor nerves resulting 
in irregular jerking movements, interfering more or less with the 
voluntary action. 

Symptoms. — The disease generally sets in with slight convulsive 
movements of the face or of one of the legs, which giadually extend 
and increase in severity until they embrace one side of the body, or the 
whole frame. When the disease is fully foimed, the patient is in 
almost constant motion ; the head is jerked to one or other side ; if 
standing, the foot shuffles and scrapes the floor. The walk is hurried 
and uncertain ; sometimes the affected leg is not lifted but dragged 
along, as if the whole limb were paralytic ; and when an attempt is 
made to lift it, the limb becomes irregularly and ludicrously agitated. 
Even when the extremity is at rest, the foot is often turned alternately 
outwards and inwards. The arm of the same side is similarly affected, 
so that in trying to raise anything to the mouth, the patient often jerks 
it over the head, and succeeds only after repeated attempts ; and swal- 
lowing is performed hastily and with ludicrous grimaces. If the 
patient be told to hold the arm extended, he cannot keep the fingers 
steady, but the arm is soon withdrawn, the movement being generally 
accompanied or followed by a grimace. The muscles are usually quiet 
during sleep ; but there are exceptions to this rule. The health is 
generally only slightly impaired ; but constipation is an almost constant 
symptom, and there is sometimes loss of appetite, a foul tongue, and 
offensive breath. In females, the uterine functions are sometimes dis- 
ordered. Incoherence is an occasional accompaniment. A bellows 
murmur is often heard over the heart. 

The disease affects weakly boys and girls, but rarely attacks adults, 
and when it does so, the choreic movements are limited. The following 
is a good illustration: — A maiden lady, aged 60, had been affected for 
two years with convulsive movements of the muscles on the right side 
of the neck, twisting her face during her waking hours towards her 
right shoulder. While in this position it was jerked fifty times a 
minute still further backwards. Sometimes the head was jerked 
suddenly backwards. When walking she was impelled to go fast, 
and sometimes stumbled. There was no evidence of ceiebral or 
spinal disease ; the health was otherwise good, and she took regular 
exercise. When her attention was fixed upon some object the move- 
ments decreased. During sleep and when the attention was fixed, as in 
reading, the convulsive movements ceased. The affection commenced by 
a screwing of the right side of the face into the pillow when she lay 
down at night. It was removed by the internal administration of 
sulphate of copper and the use of the sponge bath. 



HYSTERIA. 407 

Causes. — Predisposing. General weakness and irritability of the 
nervous system ; youth (from 7 to 15 years) ; female sex. It may 
occur in adults of both sexes to the age of seventy. — Exciting. Intes- 
tinal irritation from constipation or worms ; uterine irritation ; strong 
mental excitement, as from fright or anger ; blows or foils ; irritation 
of the spinal cord or its membranes. In many cases rheumatism has 
preceded the disease, or is still associated with it, and is therefore con- 
sidered by some physicians to be a cause of chorea as well as of the 
cardiac disease which frequently accompanies it. 

Prognosis. — Favourable in the great majority of cases. 

Treatment. — Indications. I. To remove causes of irritation. 
U. To improve the general health. 

I. By far the most common cause of irritation is in the bowels, and 
purgatives, judiciously and perseveringly administered, are the chief 
remedies ; in most cases, perhaps, the only efficient ones, A dessert or 
table-spoonful of castor-oil, or other simple aperient, may be given 
every other morning. More active purgatives may be used if necessary. 
The bowels should be kept open once or twice daily, but hypercatharsis 
should be carefully avoided. The evacuations should be inspected daily ; 
and the purgative plan persevered in till the discharges assume a healthy 
appearance. In many cases, nothing more will be required. 

Hemlock is a valuable remedy when the disease arises from centric 
irritation. From 3iss to 3iv, or more, of the succus conii, maybe given 
once, twice, or thrice a day.* 

If the source of irritation be in the uterus, remedies appropriate to 
the disorder of that organ must be given. If there be tenderness of the 
spine, the case should be treated as one of spinal irritation. 

II. The general health may be improved by tonics, of which the 
sulphate and valerianate of zinc, the ammonio-sulphate of copper, and 
the sulphate or peroxide of iron, in full doses, are the best, aided by cold 
affusion or the shower-bath, with nourishing diet, fresh air, and regular 
exercise. (One of the worst cases of chorea that I have seen, and one 
which combined constant restlessness and grotesque actions of the 
muscles with mental incoherence, was cured within ten days by aperient 
medicines only. — G.) 



HYSTERIA— HYSTERICS. 



Definition. — A nervous disorder, usually attended with marked 
disturbance of the functions of digestion and respiration, and character- 
ised by convulsive fits in which those functions are signally affected, and 
the controlling power of the will strangely impaired, without complete 
loss of consciousness. 

Symptoms. — The hysteric paroxysm, or fit, is generally preceded by 

* " On the physiological action and therapeutical use of Conium, &c," by 
the Editor. 



408 TREATMENT OF HYSTERIA. 

an uneasy sense of fulness and weight at the pit of the stomach, with 
nausea, acidity, heartburn, and flatulence ; followed by sighing, yawn- 
ing, and stretching, dejection of spirits, shedding of tears, alternate 
chills and flushings, difficulty of breathing, and palpitation. There is 
often a sharp pain in the left side, about the flexure of the colon, with 
the sensation of a ball or globe rolling about, and a peculiar gurgling 
and rumbling sound, known as Borborygma {globus hystericus), and gra- 
dually rising into the stomach, and hence to the throat. The fit having 
arrived at its height, the patient appears threatened with suffocation ; 
the face is flushed, the nostrils are distended, the abdomen is protruded 
and tympanitic, the head is thrown forcibly back, and the limbs are 
strongly convulsed. The patient bursts into violent fits of laughter, 
sobbing, or screaming, utters incoherent expressions, and is in a state of 
temporary delirium ; from which, however, she is readily roused so rs 
to answer questions rationally. The spasms at length abate, a quantity 
of flatus is noisily expelled by the mouth, and there is an abundant 
flow of limpid urine ; and the patient recovers, recollecting imperfectly 
what has taken place. The fit is often followed by a severe pain in the 
head, and a sensation of soreness over the whole body. 

Sometimes the hysteric fit consists in a sudden apparent loss of speech, 
sense, and motion, with a distinct recollection of what has been said and 
done. Sometimes, again, it is characterised by a sudden access of 
laborious breathing, swollen neck, flushed cheeks, and a closed and 
trembling eyelid ; and the patient recovers, crying and sobbing. 

Causes. — Predisposing. Female sex ; celibacy ; the age from 
puberty to the fifty-fifth year ; studious and sedentary life ; grief ; 
anxiety ; delicate health ; plethora ; the scrofulous diathesis. It is rare 
in the male sex, but may occur, under mingled debility and mental 
excitement. — Exciting. Constipation ; dyspepsia ; flatulence ; exces- 
sive evacuations ; suppression of the menses or lochia ; the plethoric and 
anaemic states ; violent emotions ; imitation or sympathy ; tight lacing, 
or other impediments to the breathing. Spinal irritation. 

Diagnosis. — From epilepsy, by the retention of consciousness, and 
of some voluntary control over the convulsive movements ; by the 
marked affection of the respiratory muscles, as shown in sighing, sob- 
bing, and yawning, cries, shrieks, and laughter ; by the absence of any 
great distortion of the features ; and by the peculiar trembling of the 
eyelid. (This latter sign is of great value, for whenever it is present, 
whether in men or women, whatever the name given to the disorder, 
whether hysteria, catalepsy, trance, or mesmeric slumber, it is a sign 
of safety, and strongly suggestive of cold affusion. — G.) From mimosis 
inquieta, by the marked character of the hysteric fit ; but true hysteric 
fits may be superadded to the group of symptoms which bears that 
name. 

Prognosis. — Favourable. In males affected with hysteria there is 
some ground to apprehend future mental unsoundness. 

Treatment. — I. During the fit. II. During the intermissions. 



TREATMENT OF HYSTEEIA. 409 

During the fit. — In general nothing more is necessary than to dash 
cold water repeatedly into the face ; to restrain the patient with a loud 
and decided tone. The stays should be loosened, and ammonia applied 
to the nostrils. Assafcetida, aether, valerian, castor, opium, &c, are of 
little use. 

The persevering use of cold water as a shock, not only serves to re- 
move the existing attack, but often effects a cure after antispasmodics 
have been used in vain. In a young man who had had repeated attacks 
of hysteria in a marked form, and had taken the strongest and most 
nauseous remedies for several weeks without effect, this simple means 
speedily effected a cure. I have seen a prompt and a permanent cure 
follow the disuse of tight lacing. (G.) 

During the intermissions. — The bowels must be kept free by gentle 
aperients ; and the dyspeptic symptoms removed by appropriate reme- 
dies. If there be debility, stimulants or tonics, of which the metallic 
are the best, will be required ; if plethora be present, a restricted diet. 
Ansemia, spinal tenderness, mimosa inquieta, and disorders of the uterine 
function, require the remedies proper to these disorders. Change of 
scene, cheerful society, regular exercise, and the shower-bath may be 
prescribed with advantage. 

Hysteria is common in perverse and irritable females, and in persons 
of both sexes possessed of little self-control. The education of young 
girls of the present day, combining, as it does, excessive mental, with 
strongly defective physical exercise, predisposes to hysteria. 

Hysteria is rare in strong-minded females : and of three cases which 
have come under my notice in the other sex, two occurred in men 
remarkable for their want of self-control, one of whom became insane ; 
and the third was a single attack occurring in a medical student, on 
obtaining a prize for which he had long been anxiously striving. (G.) 

In the foregoing description, the term hysteria has been restricted to 
a disorder accompanied by fits, but it is usual to give to this term a 
much more extended meaning, and to designate as hysterical all the 
more obscure diseases of females. This indiscriminate usage of the term 
often leads to unsatisfactory views of the real condition with which we 
have to do. There are affections, however, which may, without im- 
propriety, be designated as hysterical ; such as aphonia, dysphagia, dry 
noisy cough, dyspnoea, hiccup, flatulence, paralysis, syncope, brow ague, 
irritable breast, besides a large class of anomalous nervous affections, 
which often closely simulates diseases of a more formidable character. 
The mind of hysterical females is often in a state bordering on insanity ; 
an intense desire for sympathy being the mainspring which sets the 
strange machinery in motion. The mind, in fact, is in the same state 
as the body ; and as the convulsive movements are partly due to an 
excited state of the reflex function, and partly to an absence of self- 
control, so the extraordinary mental condition is the effect of the ex- 
tension to the brain of the same condition of the nerves accompanied by 
the same absence of self -control. 

We shall often be greatly assisted in determining the true nature of 



410 TETANUS. 

these anomalous diseases by observing one or other of the following 
circumstances : — 1. That the patient, seeming to labour under a disease 
which is usually accompanied by emaciation and a decided appearance 
of ill-health, loses neither flesh nor colour; so that if she has long 
been confined to bed with paralysis, her limbs remain plump and firm ; 
if she has not been able to swallow for weeks, or is troubled with 
incessant vomiting, she seems to have taken at least three meals a day; 
if she has been a martyr to excruciating pain, her face is as free from 
wrinkles as if she had never had a care or a pang. — 2. That though, in 
some anomalous cases, the patient seems to be altogether insensible, the 
pulse beats as usual, the face has its natural colour, and while all other 
paits are motionless, the eyelids vibrate rapidly, and especially when any 
effort is made to rouse her. — 3. That a gieat portion of these affections 
aie associated more or less with disorders of the respiratory function. 
— 4. That the patient is, or has been, subject to flatulence, borborygma, 
globus hystericus, or well-marked hysterical fits. In the treatment of 
these disorders, the medical man must combine great firmness with 
kindness, and not spare cold water. Cold affusion is the only remedy 
which can be relied on, and is worth a whole pharmacopoeia of anti- 
spasmodics. (G.) 



TETANUS, or TRISMUS— LOCKED JAW. 

Varieties. — 1. Traumatic Tetanus. 2. Idiopathic Tetanus (in* 
eluding Tetanus neonatorum). 

Symptoms. — In most cases the onset of the disease is obscure. Trau- 
matic tetanus is generally preceded by pain at the seat of the injury. 
In both forms, the first symptom is usually a sense of stiffness in the 
nape of the neck, rendering the motion of the head difficult and painful. 
This is soon followed by a sense of tightness and stiffness in the lower 
jaw, with difficulty in swallowing. The patient also complains of pain, 
often violent, referred to the sternum, and thence shooting to the back. 
This is followed, after a variable interval, by increased rigidity of 
the lower jaw, and by spasms of the muscles of the neck, pulling the 
head strongly backwards. The teeth at length become closely and 
firmly set, when the affection is called trismus, or locked jaw ; and the 
features gradually stiffen into a ghastly fixed smile (risus sardonicus). 

As the disease advances, the muscles of the trunk and spine become 
involved, so that the whole body is bent forcibly backwards (opistho- 
tonos), or forwards ( emprosthotonos), or to the side (pleurosthotonos). 

At length the disease extends to every organ of voluntary motion ; 
the limbs are rigidly extended ; the abdominal muscles strongly con- 
tracted ; the eyes fixed ; the forehead furrowed ; the jaws strongly 
closed, and the angles of the mouth powerfully retracted and wrinkled, 
giving to the face the expression of a sardonic grin. These violent con- 
tractions occasion the most excruciating pain. The pulse is accelerated, 
the respiration suspended or laborious, the heat of the surface greatly 



TETANUS. 411 

increased, and the skin covered with a profuse perspiration. A partial 
remission of the symptoms occasionally takes place every ten or fifteen 
minutes, but they are renewed, with aggravated torture, from the 
slightest causes, even the least motion of the patient, or the touch of an 
attendant. If the patient fall asleep, the muscles relax. 

In fatal cases, the symptoms lapidly increase in severity; there is 
urgent dyspnoea, with an agonising sense of suffocation ; a cold clammy 
sweat; a small and imperceptible pulse ; froth or bloody mucus at the 
mouth ; the countenance becomes livid ; delirium sometimes supervenes, 
and the patient dies exhausted, or suffocated by the rigid spism of the 
muscles of respiration. The mind, in most cases, remains intact to the last. 

The duration of the disease varies. One case of acute tetanus is on 
record which proved fatal in a quarter of an hour ; the common dura- 
tion of fatal cases is fiom four to eight days. In cases of recovery, the 
duration varies from a week to two or three months. 

Latent Period. — From a few minutes to ten weeks. Most 
common period, from the fouith to the fourteenth day. 

Causes. — Predisposing. The male sex; robust and vigorous con- 
stitution; warm climates; the period of infancy. — Exciting. Vicis- 
situdes of temperature ; exposure to cold and damp, or to excessive 
heat ; great fatigue ; wounds, especially punctured wounds of the ex- 
tremities ; injuries of nerves or tendons by puncture or laceration ; the 
presence of irritating substances in the stomach or alimentary canal (the 
common cause of the tetanus neonatorum) ; irritation of the extremities of 
the nerves ; affections of the mind ; strychnia and other vegetable poisons. 

Morbid Anatomy. — Not constant. In some cases increased vas- 
cularity of the spinal cord and its membranes; but in many instances 
those parts are perfectly healthy, the disease being due to some remote 
irritation conveyed to the spinal marrow, and reflected on the muscles. 
Traces of injury to the nerves in cases of traumatic tetanus. The 
muscles often ruptured and gorged with blood. 

Diagnosis. — Fiom the effects of strychnia by the obscure character 
of the first symptoms, their slow development, and local character (the 
stiffness of the jaws and difficulty of swallowing preceding, often by a 
considerable interval, the affection of the muscles of the trunk and 
extremities) ; also by the interval of several hours or days which 
elapses in tetanus before the patient dies or recovers ; to this rule there 
are a few exceptions in cases of injury to the spine. Strychnine, on the 
other hand, proves fatal in from a quarter of an hour or less to within 
three hours. From tetanic spasms following the action of other poisons 
by the coincidence in such cases of other symptoms characteristic of the 
action of those poisons. 

Prognosis. — Extremely unfavourable ; more so when the disease 
arises from wounds or injury to the nerves than when proceeding 
from cold ; wmen it comes on suddenly, and soon after the receipt of 
an injury, and rapidly increases in severity, than when slow in its 



412 TETANUS. 

progress ; when the spasmodic contractions quickly succeed each other, 
and are excited by very slight causes, than when there is a considerable 
interval. Survival beyond the fourth day is a favourable circumstance. 

Treatment. — Must be directed to the relief of the excitement of 
the motor function of the cord by means of conium, tobacco (Enema 
tabaci), or the Calabar bean (^ to \ grain of the extract), remedies which 
act directly in repressing convulsive action. Of these conium is the 
most appropriate. If the patient can swallow, 3iv— 3viii of the succus 
conii may be given at intervals of a few hours. When the medicine 
cannot be given by the mouth, it may be injected into the rectum. 
Alcohol may be given with the same view, until intoxicating effects are 
produced. 

The counter-irritant plan consists in the application of blisters along 
the whole length of the spine, and in the use of electricity. When a 
continuous current of electricity is passed along a nerve its excitability 
is diminished; and M. Kemack thought that he could prove in man 
that these currents possessed the property of causing involuntary con- 
tractions to cease by preserving to the muscles the taculty of obeying 
the will. Xobili and Matteucci have succeeded in relaxing muscles 
affected with tetanic spasm by passing a current through them, the 
direction of which was the reverse of that which naturally circulates in 
the nerves. We may, therefore, hope to control the excessive electrical 
excitement of the spinal cord by passing through it a continuous cur- 
rent, from a voltaic pile or trough, taking care that the conductor in 
connection with the zinc plates be placed at the top of the spine and the 
other lower down, or upon the surface of the limbs in succession. In 
order to bring the cord within the more immediate influence of the 
current, a stout needle or two in connection with the conductor may be 
passed through the integument and muscles covering the spine. If the 
mouth continue firmly closed, food and medicines must be given by 
means of a flexible tube passed through the nostrils, or behind the last 
molar tooth, or by enemata. During the fits, the patient may be 
brought under the influence of chloroform. 

If there be any tenderness of the spine, a blister or a bladder of ice 
may be applied to the whole length of it. 

The rest of the treatment will consist in giving wine and nourishment 
at short intervals, and keeping the patient as quiet as possible. 



TETANUS NEONATORUM— INFANTILE TETANUS. 

Synonym. — Trismus nascentium. 

Symptoms. — In the second or third week after birth, tetanic spasm, 
beginning in the muscles of the jaw, and thence, in some cases, extend- 
ing to the whole body, and proving rapidly fatal. 

Causes. — Improper diet, as in the Westmann Islands off the coast 
of Greenland, where the food of children consists almost exclusively of 



HYDROPHOBIA. 413 

fish ; intestinal irritation in hot climates ; the impure air of crowded 
foundling and lying-in hospitals. Intense cold. 

Treatment. — An aperient at once, followed by a warm bath. The 
diet should be restricted either to the mother's milk, or to that of the 
cow. A drachm of castor-oil is a convenient aperient. Free ventilation 
is an essential part of the treatment. 



HYDROPHOBIA— CANINE MADNESS. 

Definition. — Intense excitability of the nervous system, with 
irritation of the fauces acting on the spinal cord through the incident 
nerves, and giving rise to reflex spasm of the muscles of deglutition. 

Symptoms. — At an uncertain interval after the bite of a rabid 
animal, pain, stiffness, or some unusual sensation, often accompanied by 
inflammation, is felt in the seat of the wound, followed, in many cases, 
by pains darting thence along the course of the nerves. These local 
symptoms are not always present. After a few hours or days, wander- 
ing pains are felt in different parts of the body, with stiffness of the 
neck and throat, restlessness, irritability, and drowsiness ; the spirits 
are depressed ; there is frequent and deep sighing, and the sleep is 
disturbed with frightful dreams. 

The true nature of the case is first revealed by an unusual difficulty" 
in swallowing liquids, which increases till it becomes intolerable ; and 
the moment any fluid is brought near the patient, or when the motion 
of the fluid is heard, he starts with horror, and the attempt to swallow is 
hurried, accompanied with sobbing or deep-catching -sighs, and followed 
by convulsions. 

There is intense irritability ; the countenance expresses great anxiety, 
alarm, and suspicion ; the eyebrows are contracted, the eyes wild, 
staring, and glassy ; there is intolerance of light and sound, urgent 
thirst, a parched tongue, a hot and dry skin, and retching. The sufferer 
often screams violently, talks in a loud, authoritative tone, and spits out 
the viscid saliva between his closed teeth, with loud and noisy strainings, 
not unlike the barking of a dog. In spite of these severe sufferings, the 
mind often remains unaffected to the last, but in other cases the patient 
lapses into wild delirium, talks incessantly and incoherently, and is in a 
state of the most distressing restlessness ; the slightest motion, or 
sudden change of position, a breath of air, a ray of light, a polished sur- 
face, or the least noise, will excite a sensation of suffocation or con- 
vulsions; delirium in some instances takes place, convulsions now 
become frequent, and the patient dies convulsed, exhausted, or as- 
phyxiated. 

Duration. — Generally from two to three days. In one case, thirty- 
six hours ; in rare instances, eight or nine days. 

Latent Period. — From three or four weeks to some months, or 
even years ; most common period from twenty to forty days. 



414 HYDROPHOBIA. 

Diagnosis. — The disease cannot be confounded with any other. The 
cause and symptoms are alike peculiar and characteristic. 

Prognosis. — Fatal. The disease has hitherto defied all remedies. 

Morbid Anatomy. — Not constant. Slight traces of inflammation 
in the spinal marrow and its membranes. Inflammation of the fauces 
and air-passages, with increased secretion. 

Treatment. — Indications. I. To prevent the absorption of the 
poison. II. To remove the irritation of the throat. III. To diminish 
the excitability of the nervous system. 

I. Persevering suction of the wound should be used without a moment's 
delay; this should be promptly followed by excision of the part, and the 
subsequent application of a poultice. If this cannot be done at once, 
and the wound is on the arm or leg, a ligature should be applied above 
the wound. This treatment is to be preferred to the use of caustic. 

II. The second indication is best fulfilled by constantly swallowing ice. 

III. The third indication may be fulfilled by powerful doses of 
conium alone, or in combination with opium. Chloroform is a very 
useful palliative. 

Ice was swallowed with great advantage in a remarkable case ad- 
mitted to King's College Hospital under the late Dr. Todd. The patient, 
a boy seven years of age, labouring under hydrophobia in its most 
marked form, and refusing, with characteristic horror and impatience, 
everything previously ottered him, whether in a liquid or solid form, 
and who had taken ten drops of dilute hydrocyanic acid, repeated at 
short intervals, and at length twenty drops in one dose, without 
apparent effect — after the most severe convulsive paroxysms which 
had yet seized him, w r as offered a fragment of rough ice. This he 
swallowed with avidity. Fresh pieces were swallowed with the greatest 
ease. In less than half an hour, he had taken about a pound and a half 
of ice. At the same time that it was given internally, a bladder con- 
taining a mixture of broken ice and common salt was applied to the 
whole length of the spine and around the throat. Under the external 
and internal application of cold, all the symptoms of hydrophobia, 
referable to the throat and chest, with the exception of occasional hawk- 
ings, had pasted away ; the viscid mucus no longer flowed from the 
mouth, the mucous rale disappeared from the chest, and nothing re- 
mained but extreme lestlessness, violent excitement, and incoherence. 
The patient sat up in bed with a large fragment of rough ice in each 
hand, talking incessantly and incoherently in a loud voice, and showing 
an aimless eagerness. The intense excitement continuing, and all the 
peculiar symptoms of hydrophobia having subsided, the cold douche 
was, in Dr. Todd's absence, applied by my directions, but the system 
did not rally from the shock. (See Lancet, January 22, 1842.) 

I am inclined to attribute more benefit to the internal than to the 
external use of ice in this case, but the joint administration, while the 
rest of the body is kept warm, seems to be the most rational treatment 
yet recommended. (G.) 



( 415 ) 



DISORDERS OF THE MIND. 

Mania ...... Furious Madness. 

Melancholia .... Melancholy Madness. 

Hypochondriasis . . . Vapours — Low Spirits. 

Delirium Tremens . . Drunkard's Delirium. 

MANIA— FURIOUS MADNESS. 

Symptoms. — This disease sometimes comes on suddenly, but more fre- 
quently slowly and almost imperceptibly. For some months or even years, 
the thoughts, habits, tastes, temper, and affections of the patient gradually 
become more and more the reverse of his former self. He suffers from 
a distressing confusion of ideas, a failure of memory, depression of spirits, 
a loss of interest in his ordinary pursuits, with extreme irritability of 
temper, restlessness, and wakefulness ; and he has a miserable consci- 
ousness of loss of mental power and change of character. The general 
health suffers ; there is pain in the head, and giddiness ; the appetite 
fails, the sleep is disturbed, the bowels are confined, or irregular, or 
affected with diarrhoea ; the tongue is furred ; the pulse frequent and 
quick ; the patient grows thin, and the features alter. Frequently 
before the disease shows itself in its marked form, the bodily health 
improves, and the painful consciousness of unsoundness disappears. 

After these symptoms have lasted for a variable period, without at- 
tracting much attention, some accident, injury to the head, mental 
shock, or unusual excitement of the mind, or some more trivial circum- 
stance, brings on decided mania. 

The symptoms of mania, whether they set in suddenly or come on 
gradually, are the following: — anxiety, uneasiness, restlessness, sleepless- 
ness, alternate excitement and depression, or continued agitation and 
violent muscular efforts, rapid and incoherent discourse, tits of loud 
laughter or shoutings, grinding of the teeth, spectral illusions, mental 
delusions, and unfounded antipathy to certain persons, particularly to 
near relations or intimate friends. There is a peculiar wildness and 
fierceness of countenance, the pupil is dilated, the eyelids widely open, 
the eyes glistening and unsteady, the features strongly marked, and the 
countenance flushed. The patient will sometimes complain of severe 
pains in the head, giddiness, loud noises in the ears, and bright spots 
before the eyes. The sensations are generally more obtuse than usual, 
or they are disregarded, so that the patient will bear the most intense 
cold or heat, prolonged abstinence from food or drink, and long-con- 
tinued want of sleep. The bowels are usually costive, and require 
strong aperients; the taste is often depraved, and the appetite variable ; 
the tongue is dry and furred ; the pulse accelerated and often full ; the 
habits are careless and negligent, and often filthy. The disease is some- 
times complicated with epileptic fits, with symptoms of paralysis, or 
with disease of the brain. 

Some maniacs have lucid intervals, which occur with regularity ; 



416 MANIA. 

others are subject to paroxysms of very irregular occurrence. They 
are also capable, under certain circumstances, of considerable self- 
restraint, and of concealing their delusions or designs, and they will 
carry out their plans with the perfect cunning and contrivance of sane 
men. 

Attacks of mania sometimes seem to suspend other diseases, such as 
gout and consumption : they may also be attended by a remarkable 
improvement in the general health ; and they are consistent with the at- 
tainment of a good old age. Relapses are common. Mania often super- 
venes on less acute disorders of the mind, and it generally passes into 
dementia, which is often complicated with paralysis. 

Morbid Anatomy. — Atrophy of the brain ; thickening and opacity 
of the arachnoid; effusion of serum beneath the membranes or in the 
ventricles ; increased or diminished vascularity of the substances of the 
brain ; softening of the grey matter, especially in cases accompanied by 
paralysis; increased density of the whole brain, or of pails of it. But 
there is no morbid appearance proper to insanity. 

Causes. — Predisposing. Hereditary tendency ; the adult age (I have 
never seen it earlier than the sixteenth year — Heberden). — Exciting. 
Violent emotions ; intense application to study or business ; immoderate 
indulgence of the passions ; violent exercise ; frequent intoxication ; 
parturition, lactation, and change of life ; blows on the head. Certain 
diseases of the brain, preceding attacks of epilepsy, and acute febrile 
disorders. 

Diagnosis. — From encephalitis, by the absence of febrile symptoms. 
From delirium tremens, by the more violent excitement, the more com- 
plete incoherence, the absence of tremor, and the history of the case. 

Prognosis. — Favourable. Following some other disease, or arising 
from some temporary cause, such as an occasional excitement of the 
mind or a single debauch ; the attacks being slight and infrequent ; 
youth ; haemorrhage ; diarrhoea. — Unfavourable. Coming on after 
the middle period of life, or having been of long continuance ; compli- 
cation with epilepsy or paralysis. 

Treatment. — In the early stage the medical treatment must be 
determined entirely by the condition of the bodily functions. Symptoms 
of determination of blood to the head, must be met by remedies suit- 
able to that state. Constipation will require the use of aperients. 
When the secretions are disordered, the patient must be put under a 
course of alteratives ; suppressed discharges must if possible be restored. 
If there be anaemia, or debility arising fi om other causes, tonic remedies 
are indicated, and if the habits of the patient be in any respect unfavour- 
able to health, a change must be insisted on. The habitual use of the 
shower-bath, change of air, a nutritious and unstimulating diet, regular 
hours for meals and rest, and an abstinence from business, with change 
of scene, and cheerful society, should be particularly enforced. The 
moral treatment will consist in removing as much as possible all causes 



MELANCHOLIA. 417 

of excitement, all unnecessary opposition to the patient's plans and 
wishes, with great forbearance on the part of relations and attendants. 

When the disease is fully developed. — If there be decided symptoms of 
determination of blood to the head, bleeding, cupping, leeching, cold to the 
head, brisk purgatives, and low diet must be prescribed. When the 
patient is extremely violent and sleepless, opium may be given with 
advantage in large doses. We may begin with five grains, and increase 
the dose till it reaches ten, fifteen, or even twenty grains ; and as much 
as half a drachm may be given in the course of the day, and continued 
for days, or even weeks. This treatment seems to be peculiarly appli- 
cable to cases brought on by exhaustion, whether from loss of blood, 
starvation, intemperance, or dissipation, and in puerperal mania. If the 
face be pale, or the attack of mania have been preceded by loss of blood, 
debilitating discharges, or exhausting diseases, tonics or stimulants, 
according to the degree of the debility, in combination with opiates, 
must be resorted to. In all cases allied to hysteria, the shock of the 
cold affusion, or the shower-bath, is highly advantageous. 

The moral treatment. — In recent cases it is necessary to prevent the 
patient from offering violence to himself or others by the strait waist- 
coat, or the coercion of powerful attendants. The fury of madmen and 
the viciousness of brutes can be tamed by similar means. While treat- 
ing him kindly, the attendant must make the patient feel that he is 
both wiser and stronger. In chronic cases, and in lunatic asylums, 
personal restraint can often be foregone, and constant watchfulness, 
gentle and conciliating treatment, and occasional seclusion, may be sub- 
stituted. Much depends upon gaining the confidence of the maniac, and 
keeping out of sight all irritating means of restraint. 

The patient should be engaged in some exercise or pursuit that will 
employ at once the body and the mind, and thus divert the latter from 
one invariable train of thought. He should, therefore, be removed from 
those objects with which he was formerly acquainted, and out of reach 
of things and persons associated with the origin of his disease. When 
there is a tendency to suicide, the most constant vigilance is required. 

Mania is only one of many mental disorders, but it is the one which the 
practitioner is most likely to be called upon to treat. The other forms of 
mental unsoundness, not treated of in the present chapter (viz., idiocy, 
imbecility, and dementia), rarely require more than moral treatment. 

For a more minute account of many of the phenomena of unsound 
mind, see Parti, p. 116. 



MELANCHOLIA— MELANCHOLY MADNESS. 

Symptoms. — This disease is characterised by dejection of spirits, 
seclusion, timidity, fickleness, and great watchfulness, and is generally 
accompanied by disorders of the digestive organs, with flatulence and 
costiveness. The mind pursues one object or train of thought, which 
usually bears a near relation to the patient himself, or to his affairs, 

2 E 



418 HYPOCHONDRIASIS. 

which he views with great and unfounded apprehension, and extreme 
depression. This painful state of mind is often attended by a strong 
propensity to suicide, in one form of the disease the patient refers 
some bodily sensation to imaginary and impossible causes, as living 
animals, or even persons, in the stomach or bowels. 

Causes. — Predisposing. Hereditary tendency to insanity. — Exciting. 
Chronic disease of the liver and organs of digestion ; suppressed evacua- 
tions ; distress of mind ; sudden mental shocks ; anxiety ; excessive 
evacuations ; intemperance. 

Diagnosis. — From mere depression of spirits by its exaggerated 
and persistent character, and the existence of delusions. The term me- 
lancholia is sometimes improperly used for monomania. 

Prognosis. — Favourable. The absence of hereditary tendency ; the 
previous short duration of the disease ; the reappearance of habitual 
evacuations; sound sleep. — Unfavourable. Hereditary predisposition ; 
the chronic character of the disease, or its association with epilepsy. 

Treatment. — The medical treatment consists in regulating the 
functions of the stomach and bowels by aperients and alteratives, and 
in the use of remedies adapted to the state of the patient's constitution. 
The shower-bath may be prescribed with advantage. 

The moral treatment consists in changing the scene, amusing the 
mind, and diverting the attention as much as possible from the existing 
train of thought; travelling, rural sports, society, conversation on 
favourite topics, and music, may be recommended, according to the 
tastes of the patient, his previous habits of life, and the experience of 
his friends or attendants. Patients who betray the slightest tendency 
to suicide must be closely and constantly watched. When the patient 
supposes the stomach or bowels to be the seat of some living animal, a 
pretended operation for its extraction will often effect a cure. 



HYPOCHONDRIASIS— VAPOURS— LOW SPIRITS. 

Symptoms. — Dyspepsia, with dull pain in the hypochondria ; languor, 
listlessness, want of resolution and activity, disposition to seriousness, 
sadness, and timidity as to future events. The patient pays particular 
attention to his health, exaggerates his symptoms, and takes very de- 
spo^ ling views of his case. 

3ES. — Predisposing. The melancholic temperament. — Exciting, 
DySj. jsia ; painful impressions upon the mind ; distressing events. 

Diagnosis. — From melancholia, by the more constant dyspeptic 
symptoms, and the absence of well-marked delusions. From dyspjepjsia, 
ly the exaggerated importance attached to existing symptoms. 

Treatment. — That proper to dyspepsia. Change of air and scene, 



DELIRIUM TREMENS. 419 

where they can conveniently be had, should be prescribed ; and the 
patient should be diverted, as much as possible, from the thought of 
his complaints. Care should be taken not to increase the disease by 
prescribing active remedies. 



DELIRIUM TREMENS— DRUNKARD'S DELIRIUM. 

Syxonym. — Mania a potu. 

While drunkenness is the commonest cause of this condition, we 
must be alert to recognise the other causes (see below). 

Symptoms. — Sleeplessness ; restlessness ; excitability ; strange illu- 
sions of the senses of sight and hearing ; and delirium, during which 
the patient recognises those about him, answers questions rationally, 
and does hurriedly what he is told to do. He talks incessantly, and 
evinces a great anxiety to be doing something; and will often be found 
busily looking, in unlikely places, after some object on which his mind 
K intent ,' or he will transact his ordinary business in a dreamy and 
strange way. He is timid and suspicious, and fancies that he is sur- 
rounded with enemies, or that he is in a strange place, from which he 
is constantly endeavouring to escape ; or he thinks that some great evil 
is impending, or has actually befallen him. His attention is constantly 
diverted by illusions of various kinds. He is rarely violent, but some- 
times exposes himself to danger in endeavouring to effect his escape. 
Trembling of the lips, hands, and muscles is generally present, and 
more particularly in speaking, or on making any effort. There is 
profuse perspiration, a moist and slightly-furred tongue, and a small, 
quick, frequent, and compressible pulse. The countenance, in the 
majority of cases, is pale, and the manner of the patient composed and 
rational, even when describing symptoms and imaginary events likely 
to excite and interest persons in their right mind. In other cases de- 
cided symptoms of phrenitis, indicated by a hot head and flushed face, 
accompany the delirium. In fatal cases, the delirium lapses into the 
typhous state, the tremor passes into subsultus tendinum, and the 
evacuations become involuntary ; or embarrassed respiration, and 
mucous rale usher in death by apncea. The disease is very apt to 
recur. 

The spectral and other illusions of the senses in the subjects of 
delirium tremens are in some respects peculiar. They generally 1. .ve 
reference to animals. The patient will listen to the arm of a ~ , '\ 
believing it a serpent, or scratch it with his nail, alleging that i ri i ne 
hiding-place of a scorpion. Sometimes he confounds inanimate with 
living objects on account of some single resemblance : thus a groom 
suffering from delirium tremens will lift up the leg of a table as if it 
were that of a horse, harness chairs with string, &c. 

Morbid Anatomy. — In traumatic delirium no morbid appearances. 
In death after repeated attacks of mania a potu, hardening of the brain, 



420 DELIRIUM TREMENS. 






aucl a little more fluid than usual in the ventricles and subarachnoid 
spaces. In cases accompanied "by symptoms of cerebral inflammation 
some fulness of the vessels and serous effusion. Alcohol has been de- 
tected in the serum of the ventricles. 

Causes. — Predisposing. The immoderate use of alcoholic liquors, 
opium, or other narcotic drugs. Mental exhaustion from intense study 
or prolonged anxiety. The summer season. — Exciting. An occasional 
debauch ; continued intemperance ; sudden abstinence from an accus- 
tomed stimulant; loss of blood ; all causes of debility; shock, physical 
or mental ; severe wounds (delirium traumaticum^. Diseases producing 
great exhaustion. 

Diagnosis. — From simple meningitis ; by the absence of headache ; 
a moist skin; trembling of the hands; illusions; the timid, suspicious, 
and excited manner, and generally by the absence of febrile and in- 
flammatory symptoms. The distinction between meningitis and a form 
of delirium tremens coming on after a single debauch, or a compara- 
tively short indulgence in habits of intoxication, is not so easily made, 
and, in extreme cases, the histoiy of the patient and of the existing 
attack will be our only guide to treatment. When the respective 
diseases are well marked, there is no difficulty in the diagnosis. 

Prognosis. — Favourable. In proportion to the physical strength of 
the patient. — Unfavourable. If the pulse be small, weak, and inter- 
mittent, and opium induces little or no tendency to sleep. 

Treatment. — Indication. I. To procure sleep. II. To sustain 
the strength. III. To reduce inflammation when present. 

I. This indication is fulfilled by full doses of opium, or its prepara- 
tions. Two or three grains of solid opium, or from half a drachm to a 
drachm of laudanum, followed at intervals of one, two, or three hours 
by a grain of opium, or from twenty drops to half a drachm of lauda- 
num, till sleep is procured, is the appropriate treatment ; other prepa- 
rations of opium, in equivalent doses, may be substituted. The opium 
may be combined with ammonia, with wine, or with the patient's 
accustomed stimulant. 

II. If the pulse be very feeble, ammonia and bark, beef-tea, brandy 
and eggs, must be freely administered. Large doses of digitalis have 
lately been recommended in delirium tremens, but it is a remedy of 
doubtful efficacy, and requires to be used very carefully. 

III. Inflammatory symptoms are best treated by cold to the head 
and blisters to the neck. The bowels should be kept moderately open, 
avoiding the use of strong purgatives. 

The patient should be watched, and the windows well secured by 
bars or shutters. One or two strong persons should be in attendance, 
and if there be any inclination to violence the strait waistcoat must 
be used. 



( 421 ) 



CHAPTER II. 

DISEASES OF THE CIRCULATING SYSTEM. 

1. Of the Heart. 

2. Of the Arteries. 

3. Of the Veins. 

DISEASES OF THE HEART. 

1. functional or Nervous Affections. 

2. Structural or Organic Diseases. 

1. FUNCTIONAL OR NERVOUS AFFECTIONS. 

Palpitatio Palpitation. 

Syncope Fainting. 

Angina pectoris .... Spasm of the Heart. 

PALPITATIO— PALPITATION. 

Palpitation denotes frequent, strong, and tumultuous movements of 
the heart, without appreciable organic lesion. It is, however, a fre- 
quent symptom of organic disease of the heart. When existing in an 
extreme degree, the beats of the heart are both heard and felt by the 
patient, especially when lying on the left side ; and they may even be 
seen by the bystander. They are sometimes accompanied by a slio-ht 
and transient bruit de soufflet, which ceases when the heart becomes 
quiet. The palpitation is attended by a painful sensation of sinking 
referred to the region of the heart or pit of the stomach, and spoken of 
as " a sinking of the heart." In some cases there is a tendency to 
syncope. Fits of palpitation often occur on first waking in the mornino-. 

Causes. — Predisposing. The nervous temperament; the female 
sex. — Exciting. Strong emotions — joy, grief, anger, sadness, fear, 
anxiety. Violent exercise. Debility following chronic and acute diseases; 
excessive loss of blood ; inordinate natural discharges ; abuse of purga- 
tives ; dyspepsia, accompanied by flatulence ; want of nourishment ; 
intemperance ; the excessive use of tobacco ; want of sleep ; anxiety 
and distress ; intense study ; dissipation and debauchery ; excessive 



422 PALPITATION. 

sexual intercourse; onanism (hence the frequency of palpitation among 
prisoners). In females, change of life. 

Palpitation frequently accompanies valvular disease of the heart, and 
it is a prominent symptom in anaemia, hysteria, spinal irritation, mi- 
mosis inquieta, and leucorrhcea, in females ; aud plethora, dyspepsia, 
bronchitis, emphysema, and pulmonary consumption in both sexes. 

Long before any other symptom of pulmonary consumption has made 
its appearance, the patient will often complain of distressing palpitation ; 
and this is so common, that palpitation, not otherwise really accounted 
for, should lead to an examination of the lungs. 

Chlorotic girls are often supposed to labour under organic disease of 
the heart, when there is only functional disturbance. They complain 
of palpitations, difficulty of breathing, and pain in the left side, and are 
sometimes leeched, cupped, and blistered when they require an opposite 
treatment. In females suffering from spinal irritation, the heart is 
often very irritable, and the pulse may exceed 160 in the minute. 

Diagnosis. — The absence of the physical signs of organic disease ; 
the peculiarly distinct character of the sounds of the heart ; the absence 
of inequality and irregularity of the pulse (except in rare cases of dys- 
pepsia); the intervals, the entire freedom, trie great frequency of the 
pulse when the finger is first placed upon it, and the gradual diminu- 
tion which follows as the patient's apprehension disappears. 

Treatment. — Idiopathic palpitation in plethoric individuals may 
require the abstraction of blood from the arm. or by leeching or cup- 
ping to the region of the heart, followed by saline aperients, low diet, 
and rest. In most cases the medicinal and hygienic treatment will be 
that appropriate to anosmia chlorosis and mimosis inquieta. But in ob- 
structive pulmonary diseases, and in valvular diseases of the heart it- 
self, the palpitation, which was at first but a symptom of these diseases, 
may subsequently become a cause of their aggravation, and our first 
endeavour mu^t be to subdue the excitement of the heart. When its 
action is very tumultuous and irregular, much benefit may be expected 
from digitalis or hydrocyanic acid. An anodyne plaster of belladonna 
or opium may at the same time be applied to the praecordia. 

In persons subject to nervous palpitations, it is of the first import- 
ance to procure tranquillity of mind ; and as a fear of organic disease of 
the heart is often present, the assurance of the medical man that the 
heart is free from structural disease will go far to effect a cure. 

Irregular and intermittent pulsations of the heait often arise from 
the causes which produce nervous palpitations, especially from dyspepsia 
attended with flatulence, and are relieved by the same remedies. But 
they may depend on organic disease of the heart. 

The pulse at the wrist and heart may be irregular and intermittent 
during health, become regular during acute disease, and return to its 
former condition during convalescence or recovery. 

Pulsation in the epigastrium is usually produced by flatulent disten- 
sion of the stomach, and is removed by carminative aperients. (Forms. 
263, 282.) 



( 423 ) 

ANGINA PECTORIS— BREAST PANG. 

Synonym. — Syncope anginosa. 

Definition. — Sadden and acute pain in the chest, referred to the 
sternum, accompanied by intense anxiety and fear of death. 

Symptoms. — This disease generally occurs in persons having every 
appearance of good health. It consists of fits, or paroxysms, which 
come on during exercise, especially when walking up an ascent against 
the wind, or after a full meal. The attack is announced by a sudden 
and violent pain across the chest, extending down the left arm, or down 
both arms as far as the insertion of the deltoid muscles, and, in some 
cases, to the wu'ists, or fingers, accompanied with a sense of stricture so 
acute as to threaten immediate destruction. The patient is instantly 
obliged to stand still, and the moment he does so all the symptoms 
vanish. After repeated attacks, the fits, excited by slighter causes, 
are more violent and last longer. They often occur on the patient's 
waking from his first sleep, and he is, at times, incapable of lying down. 
At length, a fit more violent than usual puts an end to his existence, or 
death takes place suddenly without pain or any other warning. 

Morbid Appearances. — Defective supply of blood to the muscular 
tissue of the heart, from absence of one or ossification of both coronary 
arteries, or of the valves ; morbid accumulation of fat ; atrophy of the 
heart, from fatty degeneration. In a few cases the disease has been 
caused by the pressure of tumours in the chest ; in a few others it has 
been unexplained by any morbid appearance, and death has been attri- 
buted to spasm of the heart. 

Causes. — Predisposing. The male sex; age above 50: it is rare 
in women. (Of nearly a hundred cases, three only occurred in women, 
and one in a boy twelve years old. The rest were men, near or past 
50 years of age. — Heberden.) — Exciting. Violent exercise, strong 
mental emotion, and excess of all kinds : flatulence. 

Diagnosis. — The suddenness of the attack, the acute pain, and the 
intense anxiety, are highly characteristic, and distinguish it from simple 



Prognosis. — The probable termination of the disease is sudden 
death. This usually occurs without pain, the person being found in 
bed as if composedly asleep. The fatal event is often postponed to an 
advanced age. In a small number of cases the disease is transient. 

Treatment. — Indications. I. In the paroxysm, to revive the fail- 
ing action of the heart. II. In the interval, to regulate and invigorate 
its movements. 

The first indication is fulfilled by the immediate administration of 
stimulants and antispasmodics, such as aether, ammonia, brandy and 
water, and strong coifee. The patient should always have at hand 



424 SYNCOPE. 

some diffusible stimulus, or combination of a diffusible stimulus with 
an opiate. (Form. 119.) 

To meet the second indication the patient should be directed to lead 
a quiet life, to put away all anxiety and excitement, and to avoid hurry, 
strong muscular exertions, and walking up hill. The diet should be 
light and nutritious ; food should be taken often, and in small quanti- 
ties. Whenever a feeling of weariness comes on, a little wine or 
brandy should be taken. Attention must be paid to the general health, 
and especially to the pulmonary circulation. 

A sudden sharp pain in the region of the heart sometimes attacks 
nervous and dyspeptic persons. It has been attributed in some cases, 
and with apparent reason, to excessive indulgence in strong tea. The 
pain is not attended with the extreme anxiety of angina pectoris, and 
does not extend beyond the region of the heart. The treatment of this 
affection must depend on the state of the patient's health, and the as- 
certained cause of the individual paroxysms. Benefit is often derived 
from the application of a belladonna plaster to the region of the heart. 

Spasm of the heart is described by Laennec, though considered an 
imaginary disorder by Bouillaud, who states that theie is no positive 
fact to attest its existence. But there is no reason why the heart 
should not suffer from spasm as well as other muscular organs. 

The muscular structure of the heart would also seem to be the occa- 
sional seat of rheumatism ; the symptoms being constant dull pain, in- 
creased at intervals, and palpitation, without any abnormal sound. In 
such cases, a blister is indicated. 






SYNCOPE— FAINTING. 



Symptoms. — A person about to be attacked with syncope experiences 
an indescribable distress. The sight fails, and objects appear to swim 
before the field of vision ; there is a sense of singing or buzzing in the 
ears ; the lips and countenance become pale ; a cold perspiration be- 
dews the whole body ; and the patient, if unsupported, falls senseless to 
the ground ; the pulse and breathing are almost imperceptible. In some 
cases, not the smallest sign of life can be perceived, the face has a 
death- like pallor, the extremities are cold, the eyes closed, and the limbs 
flaccid. Recovery is announced by deep, prolonged sighs, is frequently 
attended with vomiting or purging, or it may pass into epileptic con- 
vulsions. 

In milder cases the loss of sense is incomplete, the pulse is diminished 
in force and volume, the patient merely becomes pale and sick, and 
drops of sweat appear upon the brow. 

Diagnosis. — Syncope does not usually continue longer than a few 
"?conds, but in some cases it persists for several minutes. In hysterical 
Tncope the pulse beats as usual, the skin is warm, there is no pallor 
v countenance, and the eyelids vibrate. 



ADMINISTRATION OF CHLOROFORM. 425 

Causes.— -Predisposing. A nervous and delicate constitution ; de- 
bility ; profuse evacuations, especially of blood ; functional or organic 
diseases of the heart. — Exciting. Strong emotion ; severe pain ; loss 
of blood. 

Treatment. — Purely nervous syncope is rarely dangerous. The 
recumbent posture, a draught of fresh air, cold water sprinkled on the 
face and neck, and ammonia to the nostrils, will soon restore animation. 
Such articles of dress as impede respiration should be immediately 
loosened. Hysterical syncope must be treated by cold affusion. 

When fainting fits are the result of diseases of the heart, the same 
remedies must be employed, and ammonia or hot brandy and water ad- 
ministered internally. 

Since chloroform causes death chiefly by paralysing the heart's action, 
a few words on its administration, and the treatment of the state of 
profound syncope sometimes induced by it, will be appropriate in this 
place. 

Precautions to he used in the administration of Chloroform. — 1. The 
chest of the patient should be carefully examined, and if there be val- 
vular defect of the heart, or intermittent action from debility or atro- 
phy, or if there be any obstruction to the free action of the lungs, from 
tumours, interstitial deposits, and especially from emphysema, chloro- 
form must not be administered. 

2. The inhaler should be so constructed as to secure a rate of evapo- 
ration as nearly equal as possible ; and to guard against the air in the 
reservoir becoming charged with more than six per cent, of chloroform 
vapour. The instrument contrived by Dr. Sansom, and made by 
Mr. Matthews, provides these essential safeguards. 

3. The receptacle for the chloroform should be on a lower level than 
the patient's mouth, and should be carefully kept upright, otherwise 
the unmixed vapour of the chloroform, which is four times heavier than 
air, will flow undiluted into the lungs of the patient. 

4. The finger should remain on the pulse, and the eyes be steadily 
directed to the chest and face during the whole of the process. U the 
pulse intermit, or fall below 60 ; if the breathing become abnormally 
slow, or feeble and shallow, or the countenance livid, the inhalation must 
be promptly stopped. 

The state of insensibility which it is desired to induce should have the 
following character. Pulse and breathing tranquil, and the expression 
of the countenance that of ordinary sleep ; but if there have been much 
noisy struggling in the first stage, it may appear a little congested. 
The eyelids closed and insensible, the eyeball fixed, and the pupil con- 
tracted, but respondent to the stimulus of light. The skin insensible 
and the limbs flaccid. 

Chloroform kills by paralysing the heart, and death usually takes 
place with great rapidity, the breathing and pulse rapidly becoming 
slower, and, in a few seconds, imperceptible ; the pupils dilated and 
insensible to light ; the face pale and sometimes livid. 

The post-mortem appearances, due to the effect of chloroform, are 



426 ACUTE PERICARDITIS. 



I- nn A 



congestion of the Lungs, an empty and flaccid condition of the heart, and 
a fluid state of the blood. 

The means of resuscitation should always be at hand, to be promptly 
employed if the foimidable symptoms just mentioned appear. They 
are strong ammonia, hot and cold water, artific'al respiration, electricity. 
While ammonia is being applied to the nostrils and mouth, and a large 
sponge saturated with almost boiling water to the region of the heart, 
cold water should be dashed in the face, and artificial respiration em- 
ployed, the tongue being pulled forcibly forwards. If these means fail, 
electricity (by means of the magneto-electiic apparatus) maybe applied 
to both sides of the body simultaneously — one electrode being placed on 
the neck, the other on the chest, so as to direct the current from above 
downwards. 



STRUCTURAL DISEASES OF THE HEART AND 
PERICARDIUM. 

Pericarditis . . Inflammation of the Pericardium. 
Endocarditis . . Inflammation of the Endocardium. 
Carditis . . . Inflammation of the Substance of the Heart. 
Atrophy . . . Fatty Degeneration of the Heart. 
Diseases of the Valves of the Heart. 
Hypertrophy . . Enlargement of the Heart. 
Dilatation" . . Of the Heart. 
Cyanosis . . . Blue Disease. 
Extozoic Disease of the Heart. 

PERICARDITIS— INFLAMMATION OF THE 
PERICARDIUM. 

Varieties. — 1. Acute. 2. Chronic. 

1. acute pericarditis. 

Idiopathic pericarditis is of very rare occurrence. The disease is 
commonly an accompaniment of acute rheumatism. 

Symptoms. — After rigors, which are sometimes extremely severe, 
pain, more or less acute, under the left nipple and towards the inferior 
extremity of the sternum, occupying a part or the w T hole of the precor- 
dial legion, radiating towards the left axilla and arm, and sometimes 
extending down the left arm to the elbow or wrist. The pain may be 
pungent and lancinating, or dull and obscure ; or there may be merely 
a feeling of oppression. When pain is present, it is increased, when 
absent, often produced, by deep pressure in the intei costal spaces over 
the region of the heart, by upward pressure against the diaphragm, or 
by an attempt to lie on either side. There is also violent and often 
irregular palpitation. 

In addition to the cardiac symptoms, there is more or less fever ; a 



ACUTE PERICARDITIS. 427 

frequent, full, hard, regular, and jarring pulse, or a small, unequal, 
irregular, and very rapid one ; dyspnoea, or respiration interrupted by 
sighs, sobs, or hiccough ; an insupportable sense of oppression, restless- 
ness, jactitation, and an urgent want of fresh air ; the skin may be 
bathed in sweat, or very dry and hot ; the countenance is pale, sharpened, 
and expressive of extreme anxiety. Sometimes there are attacks of 
partial convulsions, or a slight and momentary delirium, and if the 
patient sleep he awakes with fearful dreams ; in other cases there is 
complete insomnolence. The anxiety and agony are sometimes so in- 
supportable that the slightest motion occasions an apprehension of 
sudden death. When the disease proves fatal, the breathing becomes 
more and' more laborious, the countenance livid, the eye glassy, the skin 
covered with a clammy sweat. 

Terminations. — 1. In complete recovery. 2. In chronic pericar- 
ditis. 3. In adhesion of the pericardium. 4. In death. 

Morbid Anatomy. — Effusion of serum, with shreds of coagulable 
lymph, or with pus, sometimes tinged with blood ; rough deposits of 
lymph on the membrane ; slight soft adhesions between the two sur- 
faces. In many cases, endocarditis, more or less extensive. 

Diagnosis. — The disease is apt to be confounded with pleuritis, 
pneumonia, or even with simple fever. When the physical signs are 
well marked, the diagnosis is easy. 

Auscultation, — Within a few hours, or one or two days of the com- 
mencement of the disease, a superficial to-and-fro sound {bruit de 
frottemenf), caused by the rubbing of the inflamed surfaces of the peri- 
cardium, corresponding to the two sounds of the heart, and resembling 
the sound caused by rubbing the hands backwards and forwards against 
each other. When the secretion of lymph is more consistent, the sound 
resembles the creaking of new leather {bruit de cuir), or in still more 
marked cases, that of a file or rasp {bruit de scie, bruit de rape). As 
the secretion into the sac of the pericardium increases, or if the opposite 
surfaces become adherent, the to-and-fro sound disappears. The sound 
is first heard a little to the left of the mesial line, and about the centre 
of the sternum, whence it gradually extends over the whole precordial 
space. It is often accompanied by a bellows sound synchronous with 
the systole of the heart, and this, which is endocardial, often remains 
when the to-and-fro sound has ceased. Sometimes it is very difficult to 
determine whether the sound be endo- or exocardial. The exocardial 
sound may be distinguished — 1. By its nearness to the surface. 2. By 
its independence of the rhythm of the heart. 3. By its limitation to 
the region of the heart — endocardial sounds are frequently prolonged 
over the great vessels. 4. By its occasional disappearance and change 
of character. Percussion detects precordial dulness, coextensive with 
the effusion. When there is much liquid effusion, the sounds of the 
heart are at first muffled, and in proportion as it increases, they 
become less and less distinct, till, in extreme cases, they are almost 
inaudible. 



4'28 CHRONIC PERICARDITIS. 

Prognosis. — Complete recovery only occurs in those cnses in which 
the effusion is fluid. Solid effusions generally lead to some roughening 
of the pericardium, or adhesion of the opposed surfaces. 

Causes. — Predisposing. He.editary tendency to rheumatic and 
gouty affections ; male sex : from 10 to 30. — Exciting. Cold, and, in 
most cases, the extension of acute articular rheumatism; neighbouring 
inflammations of the pleura and lungs ; renal disease ; pyaemia. 

Treatment. — Indications. I. To subdue the existing inflammation. 
II. To promote the absorption of effused matters. 

I. The first indication is fulfilled by general or local bleeding, accord- 
ing to the strength and state of the patient. If the disease come on 
suddenly in a vigorous plethoric person, blood may be taken from the 
arm, so as to make a decided impression on the pulse ; and this may be 
followed by cupping, or leeches over the heart. But if the disease super- 
vene, as it generally does, in the course of an attack of acute rheumatism, 
or in one whose strength is already reduced, topical bleeding by cupping 
or leeches will suffice. In no case should depleting measures be carried 
to excess. They may be assisted by purgatives, rest, and the antiphlo- 
gistic regimen ; and when the depletion has been carried to the proper 
extent, a blister may be applied over the region of the heart, and kept 
open some time by savin ointment. 

II. The second indication is fulfilled by mercury freely given every- 
one, two, or three hours, in combination with opium, and accompanied 
by mercurial inunction, till the gums are sore. In very acute forms 
of idiopathic pericarditis, the mercury may be combined with tartar 
emetic in doses of i to J of a grain. Rheumatic pericarditis should be 
treated with blisters and the appropriate remedies. 

2. CHRONIC PERICARDITIS. 

Symptoms. — Palpitation and dyspnoea, accompanied sometimes by 
dry cough ; inability to lie on the left side ; slight pain or uneasiness 
in the region of the heart ; sense of oppression ; great debility ; and 
slow and imperfect convalescence, or a fatal termination in hydroperi- 
cardium. 

CAUSES. — Chronic pericarditis is generally a sequela of the acute 
form of the disease ; and is especially apt to follow an attack of acute 
rheumatism. The symptoms are sometimes very obscure. 

Treatment. — Blisters to the region of the heart. In the rheumatic, 
the appropriate eliminatives ; in the debilitated, iron, in combination 
with iodine or quinine. During convalescence violent exercise should 
be avoided, and a nourishing, unstimulating diet allowed. 

Sequelae. — Important structural changes often remain when the 
symptoms of pericarditis, whether acute or chronic, have been removed. 
The pericardium may be thickened, and the subjacent capillary vessels 
enlarged. There may be serum, or lymph, or pus in the pericardium, 



HYDRO-PERICARDIUM. 429 

adhesions, partial or general, and organised deposits of fibrine, in the 
form of granulations and vegetations. The false membranes may become 
fibro-cartilaginous, or even osseous. The effused fluid, or the thick false 
membranes, embarrass the action of the heart. The muscular tissue 
may, like the serous, fibrous, and cellular tissue of the heart, become 
thickened, and hypertrophied, indurated or softened, by the extension of 
the inflammation from the pericardium (see Carditis). 

These changes may be detected by careful stethoscopic examination. The 
superficial to-and-fro sound of acute pericarditis is generally absent. The 
denser deposits on the surface of the pericardium are indicated by harsher 
and louder sounds, corresponding to the apex or base of the heart. Partial 
adhesions of the two layers of the pericardium are sometimes productive of 
no unusual sounds ; at others, of some modification of the friction sounds. 
Extensive adhesions of the two layers of the. pericardium generally lead 
to irregular action of the organ, and are accompanied by a well-marked 
retraction of the epigastrium, and hollowing of the intercostal spaces 
with each systole of the heart ; and the heart's beat continues to be 
perceptible in the same spot, in all positions of the body, and in all 
states of the respiration. Extensive effusion into the sac of the pericar- 
dium constitutes Hydro-pericardium. 

HYDRO-PERICARDIUM. 

Varieties. — 1. Active, from inflammatory action. 2. Passive, from 
obstruction to the circulation. 

The symptoms of the jjassice form are generally obscure. They are, 
a sense of weight and oppression in the praecordia, great dyspnoea, a 
dusky, suffused countenance, a tendency to syncope, oedema, and a small, 
frequent, irregular pulse. The patient usually sits up in bed, afraid of 
the least exertion, or slightest change of position. 

Local Sigxs. — When the effusion is considerable, prominence of the 
praecordia, with bulging of the intercostal spaces, extensive dulness, 
reaching sometimes from nipple to nipple and nearly the whole length 
of the sternum ; the pulsations of the heart imperceptible when the 
patient lies down, and shifting their place in the erect and sitting posture ; 
the sounds indistinct in the region of the heart, but more audible at the 
upper part of the chest ; the dulness varying its situation and extent 
with the posture. 

Prognosis. — Extremely unfavourable. 

Treatment. — That of dropsies in general, by drastic purgatives 
and diuretics, modified according to the state of the patient and existing 
complications, and assisted by large blisters to the region of the heart, 
kept open by savin ointment. In a few cases, where the accumulation 
of serum has been very large, and the disease is free from other visceral 
complication, tapping has been practised with success. The spot selected 
for the operation is the fifth intercostal space, through which a trocar 
of small size is introduced — from below upwards. 



( 430 ) 

ENDOCARDITIS— INFLAMMATION OF THE 

ENDOCARDIUM. 

Symptoms. — General feeling of uneasiness, anxiety, and oppression at 
the pracordia, with a tendency to syncope ; but no pain, unless the 
disease he complicated with pericarditis or pleurisy. In the more severe 
cases there is well-marked fever, hot and dry skin, thirst, and restless- 
ness ; violent and irregular action of the heart, with a small, feeble, and 
often intermittent puke ; jactitation ; cold sweats ; pale and shrunken 
features, expressive of extreme alarm ; dyspnoea, faintness. or actual 
syncope ; lividity of the lips and cheeks ; slight swelling of the hands 
and feet ; and short convulsive seizures. 

Morbid Anatomy. — 1. Redness of the endocardium, sometimes 
general, but more frequently partial ; often confined to the valves, and 
generally accompanied by some thickening infiltration, and softening of 
the membrane. 2. Effusion of white, elastic, glutinous masses of coagul- 
able lymph, firmly attached to the free borders of the valves, adherent 
to the parietes, entwined round the valvular tendons and fleshy columns, 
and often prolonged into the large vessels. 3. Vegetations or granula- 
tions, varying in size from that of a millet-seed to that of a small pea, 
single or clustered, smooth or rough, and when very numerous resembling 
the head of a cauliflower, on the free borders of the valves, and some- 
times on the surface of the cavities. 4. These valvular vegetations are 
often accompanied by fibro-cartilaginous or calcareous indurations, which 
contract the orifices of the heart so as to impede the circulation of the 
blood, and cause cardiac dropsy. Sometimes the opposite borders of the 
valves are adherent. 

Causes. — Those of pericarditis, which it often accompanies. 

Diagnosis. — The stethoscopic indications mentioned under diseases 
of the valves. The .murmurs are generally of a low pitch, and are 
sometimes musical. We cannot be sure of the existence of acute endocar- 
ditis unless the murmur be developed under observation. 

Prognosis and Terminations. — The disease is rarely fatal in its 
acute stage. Its duration is uncertain, and much influenced by the 
habits of the patient. It may continue for years, with slowly increasing 
embarrassment of the circulation ; forming chronic valvular disease, with 
hypertrophy, and ending either in sudden death or in dropsical effusions. 
If particles of fibrinous exsudation become detached from the inflamed 
valves and carried along in the arteries, they may eventually block up 
some of the smaller branches, and thus produce the condition known as 
embolism and its consequences. (See page 442.) 

Treatment. — That of pericarditis, and in the acute form, in 
vigorous subjects, active and prompt treatment is still more necessary. 

When endocarditis becomes chronic without organic disease, the 
symptoms may be alleviated by small and repeated bleedings, cupping 
or leeching ; gentle aperients ; counter-irritants ; the warm bath 
repose ; and a strictly-regulated diet. ' 



( 431 ) 



CARDITIS, or MYOCARDITIS. 

Symptoms. — Carditis, or inflammation of the substance of the heart, 
rarely occurs as a distinct affection, and the post-mortem appearances 
which characterise it have generally been found combined with pericar- 
ditis, or endocarditis, or both. The muscular tissues ot the heart may, 
however, be separately affected, as are the ordinary muscles in muscular 
rheumatism. 

Palpitation, with strong and abrupt contractions of the organ, a very 
frequent, full, and bounding pulse, and a dull heavy sensation in the 
region of the heart, with paroxysms of severe darting or shooting pain 
in the heart itself, extending to the shoulders and down to the arms, 
with some degree of dyspnoea, are the symptoms that may be expected 
in this disease. Muscular rheumatism in other parts of the body may be 
looked for. 

I have known such symptoms supeiwene on a severe attack of muscular 
rheumatism, without any indication of inflammation in the pericardium 
or endocardium. The treatment would be that of muscular rheumatism, 
with counter-irritation to the region of the heart, and, in the most severe 
cases, general or local depletion. (G.) 

The symptoms during life are often very obscure. After death we may 
find softening, suppuration, ulceration, and perforation of the cardiac 
parietes. 



ATROPHY OF THE HEART. 



Symptoms. — Occasional fainting, and transient attacks of giddiness, 
in some cases, and the symptoms of angina pectoris in others. The 
most common termination is in sudden death under change of posture 
or slight exertion, the patient having previously suffered from debility, 
with great pallor of countenance and anasarca ; but in some instances he 
is stout and apparently healthy. The respiration is sometimes affected 
in the manner described at p. 187. The pulsations of the heart are 
small and feeble, the impulse much weaker than natural, and scarcely 
felt by the hand, and the sounds indistinct. The least exertion renders 
the heart's action fast and irregular, and then the impulses become so 
feeble that some of them are not appreciable at the wrist. The pulse 
is very compressible, intermittent, and small, and, in a state of quietude, 
commonly below the natural frequency. 

Causes. — Predisposing. The male sex ; age above 50 ; habits of 
intemperance, combined with a sedentary life ; exhausting diseases, such 
as haemorrhage, typhus fever, pulmonary consumption, emphysema, of 
long standing, and dropsy. — Proximate. Compressions of the heart by 
deposits of fat, by effusion of fluid, by tumours ; carditis ; disease of the 
coronary arteries, or congenital absence of one of them. 



432 DISEASES OF THE VALVES OF THE HEAET. 

Morbid Anatomy. — Fatty degeneration of the muscular tissue of 

the heart, which is found soft, flabby, and of a dirty dark-brown, or pale 

drab colour. When incised a greasy film is left 

Fig. 54. on the scalpel. In extreme cases the wall of 

either ventricle may be broken down between the 

thumb and ringer. The fibres lose their faint 

striation, and the sarcous matter is more or less 

completely changed into fat, observable in the form 

of distinct highly refractive spherules. 

"i: :._:■-■ Fig. 54. The early, B, and the 

latter stages, A, of fatty degeneration 

ot' the muscular fibres of the heart. 

. ; i|| In b the oily particles are arranged in 

;/fs| rows, in A they are irregularly dis- 

mBSWPB tributed.) Fatty degeneration of the 

liver and kidneys, and of the aorta, 

emphysema of the lungs, and ulceration of the 

stomach, are frequent concomitants. 

x25c Treatment. — Nutritious diet, with tonics 

(Form. 144), and stimulants (Form. 2), and 

brandy ; carriage exercise. Great watchfulness on the part of the 

attendants, if the condition be suspected during life. The disease does 

not admit of cure. 




DISEASES OF THE VALVES OF THE HEART. 

Symptoms. — When the valves of the heart are the seat of disease, 
the blood is not only impeded in its flow out of the heart, but from 
defective closure of the valves is subject to reflex (regurgitation). 
The obstruction to the circulation of blood through the heart thus set 
up leads to hypertrophy of the organ, and sooner or later to congestion 
of the lungs or other viscera, ultimately ending in grave diseases, of 
which dropsy is the prominent symptom. The symptoms attendant on 
valvular disease are by no means uniform ; they vary with the valve 
which is the seat of the disease, and with the nature, extent, and 
duration of the morbid change itself. The general symptoms are 
tumultuous palpitation, a frequent pulse, a sense of weight, tightness, 
and oppression, sometimes accompanied by pain in the region of the 
heart and at the epigastrium ; dyspnoea ; an inability to lie on one or 
both of the sides ; flatulency ; frequent feelings of raininess and giddi- 
ness, or fits of syncope ; an anxious expression of countenance, with 
slight knitting of the brows : the countenance sometimes pale, some- 
times suffused. These symptoms are greatly increased by active exer- 
tion, walking up hill, or mounting stairs, and by violent mental 
emotion. In order to ascertain the effects of valvular disease upon the 
several parts of the circulation, and their influence in the production of 
disease of the viscera, it will be necessary to consider each valve sepa- 



DISEASES OF THE VALVES OF THE HEAKT. 433 

rately, premising these two facts : first, that disease may affect more 
than one valve simultaneously ; secondly, that while the valves on the 
left side are particularly prone to disease, those on the right are very 
much less liable to it. 

Disease of the right auriculo-ventricular (tricuspid) valve, allowing 
regurgitation from the ventricle into the auricle. — Proximate effects. 
Slight hypertrophy of the right cavities, and increased precordial 
dulness to the right ; epigastric and right sternal impulse. A soft 
systolic murmur at the ensiform cartilage. — Remote effects. Cervical 
veins distended, varicose, and pulsatile ; when a finger is pressed upon 
them, they do not become empty below it ; congestion of the venous 
circulation, producing corresponding obstruction to the arterial. The 
brain becomes oppressed and the patient suffers from congestive head- 
ache, and is liable to apoplexy. The liver becomes engorged with blood 
and enlarged ; and, as sequences, the portal circulation is impeded, and 
the mucous membrane of the stomach and intestines congested. Thirst, 
piles, and the passage of blood from one or other, or from both extre- 
mities of the alimentary canal, are symptoms of this condition. The 
kidneys do not long escape congestion ; hence the urine becomes scanty, 
and sooner or later albuminous : ascites, oedema of the legs, and at last 
general anasarca, follow the congestion of the internal organs. 

Disease of the right auriculo-ventricular orifice obstructing the flow 
of blood from the auricle into the ventricle. — If the tricuspid orifice 
be merely constricted, the action of the valves remaining perfect, there 
would be but slight congestion of the venous circulation without pulsa- 
tion in the veins, and a diastolic murmur would probably be heard at 
the ensiform cartilage. But such a condition is exceedingly rare. 

Disease of the pulmonary valves with permanent patency. — Proxi- 
mate effects. Hypertrophy of right cavities of the heart and its signs ; 
and "along the sternum a well-marked double murmur, similar, in 
every respect, to that observed in the ordinary case of permanently 
open aortic valves, loudest at the base of the heart, and becoming less 
distinct as the stethoscope is moved towards the apex, where it ceases 
to be audible." (Stokes.) — Remote effects. Dyspnoea, palpitation, 
some venous congestion. 

Disease of the pulmonary valves obstructing the passage of blood 
into the lungs. — If the pulmonary orifice become contracted, the pres- 
sure of accumulated blood in the right ventricle will lead to regurgita- 
tion into the right auricle, followed by general venous congestion, as 
detailed under regurgitant disease of the tricuspid valve. 

Disease, and also congenital deficiency of the pulmonary valves are 
very rare. 

Disease of the left auriculo-ventricular {mitral) valve, permitting 
regurgitation from the ventricle into the auricle, — Proximate effects. 
Enlargement of the left ventricle ; increased precordial dulness towards 
left side ; apex-beat lower and more to the left ; impulse greatly in- 

2 F 



434 DISEASES OF THE VALVES OF THE HEART. 

creased, often giving rise to a perceptible systolic thrill. A systolic 
murmur partially or completely obscuring' the first sound of the heart, 
most distinct at the ap^-x, and hardly or not at all heard at the base. — 
Remote effects. The arteries do not receive their full share of blood, and 
the pulse is consequently small and contracted ; congestion of the lungs. 

Disease of the left awiculo-ventricv.lar orifice, causing obstruction 
to the flow of blood into the ventricle. — If the mitral disease result in 
contraction of the left auricvlo-ccntricvlar orifice, as is sconer or later 
the case, pulmonaiy symptoms in pre portion to the contraction super- 
vene. The lungs become ccncesteJ, and there is constant liability to 
pulmonary haemorrhage, evidenced by pulmonary apoplexy, or haemo- 
ptysis, often to a large amount. Dyspncea is often very urgent ; bron- 
chitis is a chronic symptom. Sooner or later the obstruction to the 
pulmonary circulation is relt on the right side of the heart, its cavities 
become enlarged, general venous congestion ensues, and its ultimate 
result, anasaica, appears. A soft diastolic murmur, best heard at the 
apex, and not masking the second sound, is diagnostic of contracted 
mitral orifice. Later on, when the heart becomes enfeebled and the 
orifice much contracted, the murmur may be no longer heard. 

Lisease of the aortic voices obstructing the exit of blood from the 
left ventricle [constriction of the aortic orifice). — Proximate effects. 
Great hypertrophy of the left ventricle ; systolic thrill ; strong heaving 
impulse; a loud harsh systolic murmur at mid-sternum, inaudible, or 
nearly so, at apex. — Remote effects. If the constriction be great, the 
pulse, though regular in force and rhythm, is small, hard, rigid, con- 
centrated ; hardness and force imply hypertrophy. Weak action of the 
heart, or extreme smoothness of the constricted orifice, may prevent 
the development of rnunnur, and the opening may be no larger than 
a pea, without leading to the slightest oedema, even of the ankles. 
VTaishe.) 

Lisease of the aoHic valves preventing the closure of the orifice, and 
therefore allowing of regurgitation. — Proximate effects. Greatest 
hypertrophy of the left ventricle, and corresponding heavy prolonged 
impure ; diastolic and systolic thrill. A systolic, or diastolic murmur, 
or both, obliterating the first or second, or both sounds of the heart, 
heard best at mid-sternum. The systolic murmur is distinctly heard 
in an upward direction towards the right shoulder ; it is inaudible, or 
nearly so, at the apex. The diastolic murmur is best heard in a down- 
ward direction towards the apex, where it may become faint, or be 
still strongly pronounced. — Remote effecis. A characteristic sudden 
jerking pulse. The pulsation of the superficial ve-seis is viable, and 
accompanied by considerable movement ; slight pressure upon them 
o:ten produces a sensible thrill. 

Of all the affections of the valves of the heart this produces the 
least injurious effect on the circulation. Of itself it neve: 
dropsy. 

3:orbld Anatomy.— Dilatation of the oiinces, and incon 



DIAGNOSIS OF VALVULAR DISEASES OF THE HEART. 435 

closure by the valves ; partial adhesion of the valves ; contraction of 
the orifices with rigidity and roughening of the valves from fibrinous, 
atheromatous, cartilaginous, or bony deposits within their substance. 
Rupture of the valves or chorda? tendinae. 

Diagnosis. — Disease of the several valves and orifices may be cor- 
rectly diagnosed if attention be paid to the following points: — 

1. The left side of the heart is much more frequently affected than 
the right. — 2. Generally, when the right side is the seat of disease, the 
left side is affected also. — 3. Diseases of the right side chiefly affect 
the venous circulation, causing regurgitation into the jugular veins 
(the venous pulse). — 4. Diseases of the left side affect chiefly the 
arterial pulse, giving rise to irregularity and inequality. — 5. Disease of 
the right side generally leads to dropsical effusions ; disease of the left side 
to affections of the lungs ; and disease of the aorta to head symptoms. — 
6. Sounds, whether on the right or left side, which accompany or take 
the place of the first sound of the heart, and are synchronous with the 
pulse, are due to the passage of the blood out of a ventricle — that is to 
say, to regurgitation into the auricle, or onward movement into the 
artery of the side affected. — 7. Sounds, whether on the right or left- 
side, which accompany or take the place of the second sound of the 
heart, and are not synchronous with the pulse, are due to the entrance 
of blood into the ventricles, in consequence of the contraction of the cor- 
responding auricles, or to regurgitation from the corresponding arteries. 
— 8. Sounds heard at the base of the heart and in the course of the aorta 
towards the right clavicle, becoming less audible towards the apex, 
indicate disease of the valves or coats of the aorta. If the sound 
accompany the contraction of the ventricle, and be synchronous with a 
regular, equal, thrilling pulse, it is due to disease of the valves or coats of 
the aorta ; but if the sound accompanying the diastole of the ventricle 
be not synchronous with the pulse, which is, at the same time, abrupt 
and jerking, and the abrupt second sound of the heart be absent or very 
obscure, the sound is due to reflux through the open aortic valves. — 
9. If, on the other hand, the sound be synchronous with the systole of 
the ventricle, and with the pulse, which, at the same time, is wanting in 
volume, the sound is due to reflux from the left ventricle, through a 
diseased mitral valve, into the left auricle ; but if the sound be not 
synchronous with the contraction of the ventricle, it is due to the 
passage of the blood from the auricle to the ventricle, through a diseased 
mitral valve. — 10. The same rules apply to the right side of the heart. 
If the disease were in the pulmonary artery, the sound would be heard 
in the track of that vessel, towards the left clavicle. 

Causes. — Rheumatic fever, chronic rheumatism, gout, Bright's 
disease of the kidneys, violent exertion, obstruction to the pulmonary 
circulation, atheromatous degeneration of the valves or great blood- 
vessels, aneurism of the aorta or pulmonary artery. 

Treatment. — Must be directed to regulate the action of the heart 
and to prevent the tendency to dropsy, by relieving the systemic con- 



436 HYPERTROPHY OF THE HEART. 

gestion. It is effected by hydragogue purgatives, the occasional and 
cautious abstraction of blood by a small orifice, great moderation in 
diet, and an abstinence from all violent exertions and strong mental 
emotions. In the more advanced stages of the disease the treatment 
must be suited to the existing complications. The general principle of 
the treatment will be to avoid all excitement of the circulation, and all 
remedies which impair the power of the heart ; and, at the same time, 
to relieve any unusual embarrassment of the circulation by moderate 
depletion. Undue action of the heart may be moderated by the internal 
use of digitalis, and the external application of belladonna or opium 
plasters. 



HYPERTROPHY OF THE HEART. 

This is the direct result of obstruction in some part of the circulation, 
of which it is, therefore, merely a symptom. The hypertrophy is due 
to the increased exertion made by the heart to overcome the obstruction 
to the flow of the blood. It may affect the whole heart, or be limited 
to one or other of its chambers. 

The hypertrophy is usually accompanied by dilatation of the cavity 
or cavities. 

Symptoms. — Since the hypertrophy exactly compensates the ob- 
struction, its effects involve the heart alone. The symptoms, therefore, 
which are associated with hypertrophy must be referred to the diseases 
which produce it, and not to the hypertrophy itself. The physical 
signs of enlargement of the heart are very distinct. 

Physical Signs. — The impulse of the heart is greatly increased, 
is prolonged, and extends over a large space. It is visible to the eye, 
and forcibly raises the stethoscope ; the first sound is obscure, when 
there is little or no dilatation; louder, more abrupt, and heard over a 
larger space when the dilatation is considerable; the second sound 
obscure in the former case, unusually distinct in the latter. There is 
dulness, vaiying with the degree of enlargement, and most extensive 
where dilatation is combined with hypertrophy. In some instances 
there is prominence and increased breadth of the left side of the chest. 
When the right side of the heart is affected, the dulness is most marked 
over the lower part of the sternum, and the impulse is felt in the infra- 
sternal fossa. 

Causes. — Violent exertion ; prolonged efforts, as in gymnastic 
exercises ; plethora, valvular diseases and obstruction of the large vessels 
or in the heart itself: pericarditis and endocarditis ; chronic diseases of 
the lungs, especially emphysema ; diseases of the kidney. 

Prognosis and Treatment have reference to the diseases which 
produce the hypertrophy. (See Valvular Disease of the Heart.) 



( 437 ) 

DILATATION OF THE HEART. 

Definition. — Dilatation of the cavities of the heart without corre- 
sponding increase of muscular tissue. 

Symptoms of dilatation with thinness of the parietes. — This is most 
common on the right side ; and is characterised by fluttering of the 
heart, and a full, frequent, weak, and irregular pulse. In extreme 
cases swelling of the veins of the neck, and distinct venous pulse ; great 
dyspnoea ; a dusky skin ; a bloated and anxious countenance ; drowsi- 
ness ; slight delirium ; dropsical effusions. 

Physical Signs. — Impulse feeble, short, and flapping, or tremulous, 
felt over a greater extent than usual ; first sound short and peculiarly 
distinct, heard over a great extent of chest both before and behind. 

Causes. — Debility, ansemia ; chronic diseases of the lungs ; emphy- 
sema ; especially valvular diseases of the heart. 

Treatment. — Tonics. Repose of body and mind, careful regulation 
of the diet, aperients. Gentle opiates and sedatives may occasionally be 
of service to allay irritability ; dry cupping if there be urgent dyspnoea. 

Partial dilatation, or true aneurism of the heart, consists in a pro- 
trusion of some part of its walls from disease of the muscular tissue. 
It is an equally rare, obscure, and fatal disease, differing little from 
those of more general dilatation of the cavities in the symptoms. 
The physical signs are obscure ; the prognosis, when the disease is 
recognised, is in the highest degree unfavourable, and the treatment 
similar to that for more general dilatation — complete repose of body 
and mind, the cautious use of narcotic and sedative remedies, and, in 
cases of extreme urgency, cautious depletion. When the aneurism 
bursts, effusion into the pericardium takes place; the rupture is an- 
nounced by a piercing cry of anguish, and usually instantaneous death. 



CYANOSIS— BLUE DISEASE. 



Symptoms. — A blue tint of the skin, lips, mouth, and tongue; 
universalcoldness of the surface ; palpitation ; fits of extreme dyspnoea ; 
faintness, or actual syncope, on slight exertion, or from mental excite- 
ment ; feeble and irregular pulse ; oedema or dropsical effusions. 

Morbid Anatomy. — Various congenital deficiencies and malforma- 
tions. A communication between the two sides of the heart, or 
between the two sets of vessels arising from it, with disproportionate 
strength of the two ventricles, generally combined with narrowing of 
the pulmonary artery. Extreme contraction of the pulmonary artery 
alone. Transposition of the aorta and pulmonary artery. 

Physical Signs. — A very loud and superficial murmur immediately 
over the seat of the communication. 



438 DISEASES OF THE ARTERIES — OBLITERATION. 

PROGNOSIS. — Death during a paroxysm at an early age ; in rare 
instances the patient attains the adult age ; and in one case recorded by 
Louis, the age of fifty-seven. 

Treatment. — Rest of mind and body ; pure air ; warm clothing : 
strict diet ; careful attention to the state of the stomach and bowels : 
and cautious treatment of complications. 



DEVELOPMENT OF ECHINOCOCCUS IN THE HEART. 

This is a rare disease ; but as it may simulate valvular disease of 
the heart, tubercular disease of the lungs, embolism, disease of the 
arteries, &c, it is worthy of consideration here. The symptoms vary 
with the situation of the cyst, and are urgent and characteristic accord- 
ing as it ruptures into the right or left ventricle. The patient is 
usually well nourished. When the cyst ruptures into the right ventricle, 
pulmonary symptoms — urgent dyspnoea, bloody expectoration, severe 
pain in the prarcordia, and death by suffocation — results. If rupture 
takes place into the left ventricle, the symptoms are more remote and 
obscure. Mortification of a part or limb from obstruction of a large 
artery by one of the secondary or tertiary cysts, is a likely result. 



DISEASES OF THE ARTERIES. 
OBLITERATION OF THE ARTERIES. 

The arteries are liable to obliteration from any cause which for a 
time arrests the circulation through them. It appears that when their 
coats are inflamed the current of blood is retarded, and at last completely 
stagnant : coagulation then follows, the clot adheres to the walls of the 
contracted tube, and is at last converted into a fibrous cord. The most 
common cause or obliteration is a process termed by Virchow embolism, 
i.e., the impaction of clots, fibrinous concretions, or atheromatous matter, 
in the remote arteries. 

Symptoms. — Inflammatory obliteration is not necessarily attended 
by other than local symptoms, such as tenderness and haidness of the 
vessel. The p>ocess is usually slow enough to allow of the establish- 
ment of collateial circulations. If moie than one of the main trunks 
were simultaneously arlected, dry gangrene would lesult. Embolism 
occurring in the extremities, would also lesult in gangieue. If it occur 
in the internal carotids, softening of the brain, loss of vision, and 
hemiplegia may, one or all, result. If the pulmonary artery be blocked 
by a clot at its bifurcation, death, more or less sudden, from asphyxia, 
will be the consequence. If the smaller superficial arteries be tne seat 
of the embolism, sloughing ulcers may ensue. 



( 439 ) 



ATHEROMA. 

This term comprises both fatty and calcareous degenerations of the 
blood-vessels, atheroma proper being an intermediate condition. After 
the age of fifty the walls of the vessels are very liable to degeneration. 
The aorta, in particular, becomes dilated, the elasticity of its wall im- 
paired, and its inner surface roughened by large, irregular, whitish, 
elevated patches of morbid matter, composed of a mixture of earthy 
and fatty matter, and lying immediately beneath a superficial layer of 
the inner coat. 

Symptoms. — When the disease affects the smaller arteries, such as 
the radial and temporal, they become rigid and tortuous, and feel like 
cords. A dilated atheromatous condition of the aorta is indicated by 
a loud systolic bellows murmur, commencing at the mid-sternum, and 
extending thence towards the right shoulder, most distinct to the right 
of the sternum, and thus distinguished from murmurs due to disease 
of the aortic valves. Atheromatous disease of these valves is, however, 
very frequently associated with a similar degeneration of the contiguous 
part of the aorta. Owing to the diminished elasticity of the diseased 
artery, the pulse has the same sudden, jerking character as in regurgi- 
tant disease of the aortic valves. (See page 434). 

Morbid Anatomy. — At first an opaque whitish spot is observed on 
the inner surface of the artery. It consists of a fatty degeneration of the 
tissues, immedi- 
ately beneath the Fi S- 55 « 
innermost layer. 
A vertical section 
presents the ap- 
pearance shown in 
Fig. 55 : % being 
the unaltered in- 
nermost layer ; at 
h the corpuscles of 
connective tissues 
are enlarged ; at 
p these cells are 
observed to be multiplying ; at a the fatty degeneration in these ceils 
is seen commencing ; at a' they are in an advanced stage. 

The next stage of the process consists in the deposit of molecules of 
earthy matter, and the separation of cholesterin. If we examine the 
disintegrated portion of the arterial wall at this stage, we observe large 
rhombic plates or prisms of cholesterin ccc (Fig. 56); and cells 
of the internal coat transformed into fatty-granule globules a a, im- 
bedded in free granular matter, composed in part of earthy matter, and 
in part of free large and small drops of oil. (Virchow.) These accu- 
mulated deposits either form a pultaceous matter, which may be dis- 
charged into the blood through an aperture formed in the internal coat, 




440 



ANEURISM OF THE THORACIC AORTA. 



leaving the so-called atheromatous ulcer ; or they may, by the increase 
of the earthy particles, become petrified into irregular ossific plates. 

In the smaller arteries the ossifi- 



Fig. 56. 



cation proceeds much more uni- 
formly, and they become at last 
more or less completely converted 
into smooth bony tubes. 

The capillaries are equally 
liable to degeneration. When 
their walls are invaded with fat, 
they present a granular appear- 
ance. 

As a result of this condition 
their elasticity and contractility 
is impaired, they become per- 
manently dilated, and the blood 
tends to become stagnant in them. 

Effects. — Proximate. Rup- 
ture ; atheromatous ulceration of 
the inner coat, with aneurismal 
dilatation of the outer ; dilatation 
resulting first in congestion, and 
finally in rupture of the capillaries, especially those of the brain, 
causing sanguineous apoplexy. — Remote. Hypertrophy of the heart; 
embolism. 

Causes. — The rheumatic and gouty diathesis. 

Treatment. — The avoidance of hurry, exertion, and fatigue ; animal 
diet ; tonics in combination with alkalies. 




ANEURISM OF THE AORTA. 

1. ANEURISM OF THE THORACIC AORTA. 

Symptoms. — The general symptoms produced by an aneurismal 
tumour in the chest are the same as those due to any other tumour 
of equal size and similar situation — dyspnoea, and more or less con- 
solidation of the lung from pressure of the aneurismal tumour ; a 
harsh, harassing cough, with little or no expectoration, from pressure 
on the bronchial tubes ; aphonia, and paroxysmal constriction of the 
glottis, from tension of the recurrent laryngeal nerves ; dysphagia, from 
pressure on the oesophagus; obstruction to the venous circulation, 
accompanied, in extreme cases, by dropsical effusions into the cellular 
membrane of the face, neck, chest, and upper extremities, from compres- 
sion of the large venous trunks ; neuralgia of the back and paraplegia, 
from pressure on the spine, from absorption of the vertebrae ; defective 
nutrition, from pressure on the thoracic duct. 



ANEURISM OF THE ABDOMINAL AORTA. 441 

Diagnosis. — Difficult, when the tumour occupies the origin of the 
aorta, or when, whatever its situation, it is of small size. When it 
involves the arch of the aorta, or its first branches, and especially when 
it has so far increased as to rise out of the chest, the diagnosis becomes 
comparatively easy. When, again, the tumour, by its gradual increase 
in size, causes the protrusion of the sternum or ribs, or leads to their 
absorption, its strong heaving impulse will make the diagnosis certain. 

A whizzing sound, or a bellows murmur, sometimes single, or double, 
is usually heard in the situation of the tumour ; but these sounds are 
not always present, nor are they to be depended upon in the absence of 
other symptoms, since they may be produced by any tumour pressing 
upon the larger arteries. A peculiar thrilling sensation communicated 
to the hand, and a quick thrilling pulse, are occasionally present. When 
the tumour occupies the arch of the aorta, or the large vessels of the 
neck, or upper extremity, we may expect to find some marked inequality 
in the pulsations of the radial and carotid arteries. Sometimes there is 
an absence of the pulse at the wrist, of one or of both arms, and occa- 
sionally of one or both carotid arteries ; and there are signs of disturbed 
circulation through the brain, such as giddiness, faintness, and indistinct- 
ness of vision. Haemorrhage from the lungs or stomach will have 
additional value as a sign of aneurism in the ascertained absence of 
symptoms of pulmonary consumption and obstruction to the portal 
circulation ; if the tumour be at all large, dulness and bronchophony in 
proportion to the compression of the lung will be observed. A sensation 
of throbbing in the chest, difficulty of deglutition, and, in the later 
stages, vomiting and spasmodic dyspnoea, complete the evidences of 
thoracic aneurism. 

Prognosis.— Unfavourable ; but the disease progresses slowly. 

Treatment. — Perfect repose of mind and body, a cool moderate 
diet, a free state of bowels, occasional cautious depletion when urgent 
symptoms require it ; a belladonna piaster to the region of the heart, 
and digitalis in small and repeated doses to moderate the action of the 
heart. The dry harsh cough will require the use of sedatives, with 
expectorants, and anasarca must be treated by the remedies prescribed 
under that head. 



2. ANEURISM OF THE ABDOMINAL AORTA. 

Symptoms. — These vary with the size and situation of the tumour, 
and the viscera upon which it presses. When the aneurism presses on 
the stomach, it gives rise to severe gastric disturbance ; on the nerves 
of the solar plexus, to neuralgic pains ; on the bowels, to obstinate con- 
stipation or violent colic ; on the nerves issuing from the spine, to 
severe pain in the loins, abdominal parietes, or lower extremities, simu- 
lating rheumatism of those parts, sciatica, lumbar and psoas abscess, or 
disease of the spine. By pressure on the rectum, it has sometimes led 
to a suspicion of stricture of that part. When the tumour occupies the 



442 DISEASES OF THE VEINS. 

upper portion of the abdominal aorta, it may thrust up the diaphragm, 
and give rise to dyspnoea, and other symptoms of pulmonary disease. 

Diagnosis. — A tumour occupying the situation of the aorta, strongly 
pulsatile, and having the peculiar thrill above mentioned, accompanied 
by a short, harsh, bellows murmur. The pulsation is more uniformly 
diffused over an aneurismal tumour, than over any other lying upon 
the aorta ; and the bellows sound is more harsh and grating than that 
occasioned by the pressure of such other tumours. It should be borne 
in mind that the pulsation of a healthy aorta may be communicated to 
a loaded intestine or other tumour seated over it. 

The prognosis and treatment are those of aneurism of the thoracic 
aorta. 

Morbid Anatomy. — Laceration of the internal coats of the artery, 
and saccular dilatation of the external. Extravasation of blood between 
the layers of the artery, causing their dissection and dilatation. But 
the commonest cause of aneurism is fatty or atheromatous degeneration. 



DISEASES OF THE VEINS. 

Phlebitis .... Inflammation of the Veins. 
Phlegmasia Dolens . White Leg. 

Preliminary Observations. — Tlvrombosis, Embolia, and Pyaemia. 
— Before describing diseases of the veins it is necessary to say a few 
words on the formation of clots in the circulatory organs, to which 
process the term thrombosis has been given. When foreign matters 
are introduced into the vessels, the blood coagulates upon their surfaces. 
This is true of solid metallic bodies, such as iron ; and of liquids, such 
as mercury and pus. Further, a clot of fibrine, or of blood formed 
within the blood-vessels, tends to increase by superposition of layer 
upon layer of coagulum. Thrombosis, therefore, may be caused by 
phlebitis, arteritis, and endocarditis, in consequence of solid inflamma- 
tory exsudations on the inner surface of the veins, arteries, or heart. 
A film forms on the roughened inflamed surface ; and, subsequently, 
layer after layer is deposited until a clot or thrombus of considerable 
size is formed, which is attached by one extremity to the inflamed sur- 
face, while the other extremity may freely vibrate in the passing current 
of blood, or may reach to the other side of the vessel and obstruct the 
flow of blood from below. 

The subsequent changes which these clots undergo give rise to some 
of the most interesting and important pathological processes. If they 
slowly deliquesce without undergoing further change, no bad effects 
result. If the entire thrombus, or a large fragment of it be detached, 
it may be carried fiom a large vein into the pulmonary artery, and 



PHLEBITIS. 443 

produce instantaneous suffocation ; thrombi from the left side of the 
heart may become impacted in a carotid or brachial artery ; clots from 
the surface of the aorta may block up any of its branches : in either 
case sloughing ulceration of a part, or mortification of the whole limb, 
will most probably ensue. It" the clot undergo gradual disintegration 
into fine particles, these will be arrested in the capillary circulation, 
giving rise to capillary embolia, resulting in softening or ulcerative 
degeneration of the contiguous part. But even greater evils may re- 
sult from the presence of clots in the circulation. If we examine these 
thrombi, we frequently find their central parts occupied by a puriform 
mass, caused by transformation of the clots themselves. Under the 
microscope, this disintegrated matter 

is found to be composed of granules Fig. 57. 

(a, rig. 57) derived from the disin- 
tegrated fibrin ; corpuscles undistin- A 
guishable from pus corpuscles (b) ; °^ t 
and altered blood discs (c). Now, ■*"." 
the question arises, what are these »cS 
cells ? Virchow says, " Colourless 
blood corpuscles set free by the 
softening ;" others consider them 
to be true pus cells. We coincide 
entirely with the latter view, for — 
1» Evidence is wanting to prove 
that leucocytosis can take place to 
this extent in the blood itself. 
2. From the effects of the metamorphosis above described, which 
we believe to be those of pyaemia. Whether the pus cells be de- 
rived externally from a suppurating wound, in the manner described 
under pyaemia at p. 334, or internally from purulent metamorphosis 
of the clot itself, the result is the same. Wherever they are carried, 
the pus - cells form the nuclei of other clots, which, in process of time, 
become centres of suppurative inflammation ; and thus abscesses may 
be simultaneously deposited in all parts of the body. 




PHLEBITIS— INFLAMMATION OF THE VEINS. 

Varieties. — Adhesive, and suppurative (pyaemia). 

Pathology. — Idiopathic adhesive phlebitis commences in inflam- 
mation of the coat of the vein, causing its dilatation and such impair- 
ment or loss of contractility, that stagnation and subsequent coagula- 
tion of the blood is the interior result. The disease is strictly local at 
first, and if the coagulated blood be very gradually disintegrated or 
absorbed, it may remain so, and the vein may be ultimately restored 
to its original condition. If, however, portions of the coagula become 



444 PHLEBITIS. 

detached, embolism may result. If they undergo purulent degenera- 
tion, the phenomena of suppurative phlebitis (pyaemia) appear. 

Symptoms. — When occurring in the superficial veins, swelling and 
induration, sometimes accompanied by redness, in the course of the 
vessels ; pain increased by pressure ; oedema of the cellular tissue, and 
enlargement of the veins below the seat of the disease. When the 
disease assumes the supurative form, then arise all the symptoms of 
pyaemia (see p. 334) — namely, rigors, followed by profuse sweats, offen- 
sive diarrhoea, great weakness, anxiety, and irritability ; a very frequent, 
weak, and sometimes intermittent pulse ; a dry, brown tongue ; and a 
sallow skin. As the disease advances, the joints often become painful 
and tender, inflammation of the viscera, or their serous investments, 
show itself, and collections of pus, with little or no inflammation of 
surrounding textures, form in different parts of the body. 

Causes. — Predisposing. Cachexia. — Exciting. In rare instances, 
cold ; in most cases, inflammation spreading from surrounding tissues, 
or injury done to the veins themselves, as in bleeding, amputation, 
extraction of tumours, tying varicose veins, and operations for haemor- 
rhoids. Phlebitis is also apt to supervene on fractures, or on opera- 
tions performed on bones; and it often originates in injuries to the 
veins of the internal viscera, as of the uterus after childbirth, and the 
umbilical cord of new-born children. 

Morbid Anatomy. — Discoloration of the inner coat of the vein ; 
inflammation and thickening of the other coats ; inflammation and 
suppuration of the surrounding textures ; formation of coagula and pus 
within the vein ; deposits of pus in the joints and serous cavities, or in 
the spleen, or kidneys ; but more especially in the lungs and liver. 

Diagnosis. — From inflammation of the absorbents, by the absence 
of superficial redness and the larger size of the inflamed vessel, which 
feels like a large, hard, knotted cord, and is tender. 

Prognosis. — Favourable in inflammation of the external veins, 
arising spontaneously or from cold. Less favourable in phlebitis fol- 
lowing wounds, or injury to the veins. Secondary abscesses in external 
parts may be regarded as favourable. 

Treatment. — Leeches in the course of the inflamed vein. A position 
favourable to the return of blood to the heart. Warm fomentations. 
If the accompanying fever be great, aperients, or calomel and opium ; 
if of the typhous character, wine, brandy, and diffusible stimulants, in 
combination with opium. In most cases the strength must be sup- 
ported by bark or quinine, with a liberal allowance of wine or brandy. 
Close attention should be paid to uneasiness or pain in parts of the 
body ... mote from the seat of the disease, as indicating collections of pus 
requiring prompt relief by the knife. 



h 



( 445 ) 



PHLEGMASIA DOLENS— PHLEGMASIA ALBA— WHITE LEG. 

Definition. — Obstruction, usually of an inflammatory character, 
of the femoral vein, or of the femoral and iliac veins. 

Symptoms. — From one to five weeks after delivery, a painful elastic 
swelling of one or both legs, beginning generally in the groin, labia, 
and thigh, and thence extending downwards; characterised by great 
heat and tenderness, a pale, shining surface, and stiffness of the limb. 
It is commonly ushered in by rigors, with pains in the loins or belly ; 
and is accompanied by fever, thirst, a quick and frequent pulse, head- 
ache, nausea, and a furred tongue. 

Causes. — Predisposing. The puerperal state. — Exciting. Inflam- 
mation of the iliac and femoral veins, generally commencing in the 
veins of the uterus and viscera of the pelvis. 

Pathology and Morbid Anatomy. — Those of adhesive phlebitis. 

Diagnosis. — From oedema, by the absence of pitting on pressure. 
From common inflammation by the pale, shining aspect of the surface. 

Prognosis. — Generally favourable, but recovery often tardy. 

Treatment. — In acute cases, leeches to the most painful parts of 
the limb, followed by warm fomentations ; opium in large doses, with 
calomel or blue pill, given so as to affect the mouth. The limb should 
be placed in the horizontal position or slightly raised ; and the bowels 
should be kept free. If there be much fever, saline diaphoretics. In 
chronic cases, after the inflammation has subsided, iodide of potassium ; 
inflictions of mercurial or iodine ointments. 



( 446 ) 



CHAPTER III. 

DISEASES OF THE ORGANS OF RESPIRATION. 

1. Of the Larynx and Trachea. 

2. Of the Bronch:al-tubes and Air-cells. 

3. Of the Substance of the Lungs. 

4. Of the Pleura. 

DISEASES OF THE LARYNX AND TRACHEA. 

Laryngitis Inflammation of the Larynx. 

Aphonia Loss of Voice. 

Tracheitis Croup. 

Laryngismus Stridulus . Crowing Inspiration. 

LARYNGITIS— INFLAMMATION OF THE LARYNX. 

Synonym. — Cynanche laryngea. 
Varieties. — 1. Acute. 2. Chronic. 

1. acute laryngitis. 

Symptoms. — The disease sets in with rigors, followed by pyrexia, 
and usually by some inflammation of the tonsils, a hoarse voice, a husky 
and convulsive cough, constant hawking of glutinous mucus, with pain 
and constriction in the laiynx, generally increased by pressure. The 
respiration is difficult and sonorous. There is great pain in deglu- 
tition, and particles of food and liquid are apt to get into the imperfectly 
closed glottis, causing convulsive fits of coughing, and dyspnoea. The 
fauces are generally found red and swollen ; and, if the tongue be 
pressed downwards and forwards, the epiglottis may be seen thickened, 
inflamed, and erect. There is inflammatory fever, with flushed face, 
hot skin, and full, hard pulse. These symptoms are tbilowed by others 
of a more formidable character. The countenance becomes pale and 
anxious ; the lips livid ; the eyes suffused ; the nostrils expanded ; the 
pulse frequent, feeble, and inegular; the voice reduced to a whisper, 
or lost ; the threat often ©edematous. There is extreme restlessness, 
and urgent fear of suffocation. The patient is obliged to maintain the 
sitting posture, and if he fall asleep he soon awakes dreadfully agitated, 
gasping and struggling for breath. Delirium and coma ensue, and 
death takes place in from four to five days. But the patient may die 
suffocated at a much earlier period. 



ACUTE LARYNGITIS. 447 

Morbid Anatomy. — Injection and thickening of the lining mem- 
brane of the larynx, with oedema of the submucous tissue, and sur- 
rounding cellular membrane. The glottis and epiglottis red, swollen, 
and infiltrated with serum, or pus. In some cases oedema of the glottis 
is the only post-mortem appearance. 

Diagnosis. — From spasmodic affections of the larynx, by the pre- 
sence of fever and local pain, and by the gradual progress of the disease ; 
from tracheitis, by the absence of the peculiar stridulous voice, and of 
the croupy inspiration ; and, as a general rule, by the great age of the 
patients. 

Prognosis. —Unfavourable if the dyspnoea be extreme, the face livid, 
the circulation languid, and the head affected. Decrease of dyspnoea, a 
tree expectoration, an improved aspect of countenance, and greater ease 
in swallowing, are favourable signs. 

Causes. — Predisposing. Previous attacks of quinsey, frequent and 
continued exertions of the voice. — Exciting. Exposure to wet and 
cold ; extension of inflammation from the tonsils or salivary glands ; 
swallowing scalding or corrosive liquids ; inhaling acrid gases or hot 
air ; extension of inflammation in erysipelas, scarlatina, small-pox, 
measles, and diphtheria. 

Treatment. — I. The most prompt and active measures must be 
taken to reduce the inflammation and prevent effusion. Two to six 
leeches must be immediately applied over the part, followed by tar- 
tarized antimony, with calomel and antimony in full doses. A grain of 
calomel, with from an eighth to a sixth of a grain of tartarized anti- 
mony, and a third or half a grain of opium, may be given every one, 
two, or three hours, according to the urgency of the symptoms. The 
object of this treatment is to reduce inflammation by the tartar-emetic, 
to supersede inflammatory action by the mercury, and to soothe exist- 
ing irritation by the opium. 

II. If effusion have already taken place, blisters should be applied on 
either side of the larynx, and the mercury continued until consti- 
tutional effects are declared. The action may be facilitated by the 
inunction of mercurial ointment. 

When laryngitis supervenes on other diseases, the treatment must be 
modified according to the disease that may be present, and the existing 
state of the system. 

III. When, in spite of remedies, the dyspnoea increases rapidly, and 
there is urgent danger of suffocation, the operation of opening the 
trachea should be resorted to without loss of time. 

Throughout the treatment the patient should be prevented fiom 
talking. 



( 448 ) 



2. CHRONIC LARYNGITIS. 

Symptoms. — Hoarseness, sometimes increasing till the voice is re- 
duced to a whisper, or quite lost ; dry, husky cough ; pain or soreness 
in the larynx, increased by lateral or backward pressure. The c.»ugh 
is brought on by any unusual exeition, or by cold air, and is accom- 
panied, in the first stage, with scanty mucous expectoration ; in more 
advanced cases, and when ulceration is present, the sputa aie purulent, 
and mixed with streaks of blood ; or sanious and foetid. In confirmed 
cases, dyspnoea is always present, coming on generally in paroxysms, 
and leaving the patient nearly free in the intervals ; but in the last 
stage of the disease, it is increased to orthopncea, obliging the patient, 
during the fits, to sit up in bed. In the intervals of the rits the 
breathing has a peculiar hissing sound. The patient generally dies 
asphyxiated. 

Morbid Anatomy. — Inflammation and its consequences in the 
mucous and submucous textures of the larynx ; enlargement of the 
mucous follicles ; oedema ; ulceration of the mucous membrane ; ossifi- 
cation, or caries of the cartilages. 

Causes. — Those of the acute form: the inhalation of air loaded 
with dust or irritating particles of matter ; syphilis; the abuse of mer- 
cury ; tubercle. Ulceration from the cause last named occurred in 
about a fourth of the cases of phthisis quoted by Louis. 

Diagnosis. — By the permanent change of voice, the cough, the 
hissing breathing, and the pain or tenderness in the larynx. Tubercular 
laryngitis may be distinguished from simple inflammation or relaxation 
by the coexistence of the symptoms and physical signs of phthisis ; and 
syphilitic laryngitis by the coexistence of other secondary symptoms. 

Prognosis. — Favourable. The absence of signs of disease of the 
chest ; the catarrhal or syphilitic varieties of the disease. — Unfavour- 
able. Increasing difficulty of deglutition from the spasmodic cough 
caused by the passage of food into the air -tubes ; orthopncea. 

Treatment. — I. The chronic inflammation of the larynx may be 
subdued by the repeated application of a few leeches to the upper part 
of the throat, and by the use of blisters, mustard-poultices, and iodine 
ointment. The part itself should be kept at rest by the avoidance of 
talking. 

II. If the disease have a syphilitic origin, mercury should be given 
in small doses, so as to affect the mouth, or iodide of potassium, in 
five-grain doses. 

III. The tone of the relaxed mucous membrane may be restored by 
the inhalation . of steam holding some gentle stimulant in solution, as 
kreasote, camphor, turpentine, or one of the balsams ; or by the still 
stronger stimulants, nitrate of silver, and sulphate of copper, applied 
directly to the part, in a liquid or solid form. The preference should 



APHOXIA — THE LARYNGOSCOPE. 449 

be given to a strong solution of nitrate of silver, applied by a small 
probang to the epiglottis and upper part of the larynx. Solid sub- 
stances must be used in the form of an impalpable powder, and drawn 
into the larynx through a tube. Nitrate of bismuth ; calomel with 
twelve times its weight of sugar ; red precipitate, sulphate of zinc, or 
sulphate of copper, mixed with thirty-six times their weight of sugar ; 
alum with twice its weight ; and acetate of lead with seven times its 
weight — are remedies suitable for this purpose. 

IV. The paroxysms of dyspnoea, or convulsive cough, may be relieved 
by narcotics and sedatives, such as opium, asther, camphor, belladonna, 
or stramonium, inhaled or given in the form of lozenge. When the 
patient cannot swallow, it may be necessary to feed him by the oesopha- 
geal tube and stomach-pump. Where the urgent symptoms cannot be 
otherwise relieved, tracheotomy must be performed. 

V. The improvement of the general health may be effected by tonics, 
especially iron, and the mineral acids, nourishing and wholesome diet, 
bracing air, the cold or shower-bath, with strict attention to the 
functions of the stomach and bowels, and to the state of the secretions 
generally. 



APHONIA— OTHER DISEASES OF THE LARYNX. 

As every condition which impairs the function of the vocal cords 
produces a corresponding loss of voice, the causes of aphonia are very 
numerous ; and for their correct diagnosis the use of the laryngoscope 
is indispensable.. This instrument consists of two mirrors, one for the 
forehead (the frontal , the other for the mouth (the laryngeal). The fol- 
lowing are the directions for using it : — In the absence of direct sunlight, 
which is always to be preferred to artificial light, seat the patient in a 
dark room, and place an argand gas burner, or moderator lamp, so far 
behind his right shoulder that the face is in the shade, the light being 
on a level with the eye of. the operator seated in front of the patient. 
Cause the head of the patient to be thrown so far back that the light 
from the frontal mirror may shine brightly into the back of the mouth 
against the soft palate. The distance between the frontal mirror and 
the mouth of the patient which gives the brightest illumination is about 
a foot. If the patient cannot command the tongue so as to let it lie 
relaxed on the floor of the mouth, the tip, being covered with a handker- 
chief, should be seized between the thumb and finger, and drawn 
forwards. 

The laryngeal mirror is now wanned (by passing it twice or thrice 
above the flame of the lamp), and introduced to the isthmus of the 
fauces just within the pharynx, so as to tuck up the uvula and soft 
palate above and behind it ; at the same time avoiding contact with the 
tongue and back of the pharynx, otherwise expulsive action is excited. 
On depressing the handle of the mirror the back of the tongue, the 
epiglottis, and finally the vocal cords and parts bounding the aperture 
of the glottis, are brought into view (fig. 58). In some persons, and 

2 G 



450 



APHONIA. 



under favourable circumstances, the rings of the trachea, and the aper- 
tures of the right and left bronchi, may be seen as the patient takes a 
deep inspiration (fig. 59). The vocal cords appear as two ivory-like 



Fig. 58. 



Fig. 59. 




z, base of the tongue, e, epiglottis, e w, cushion of the epiglottis, s, cartilages of 
Santorini overlying the arytenoid cartilages, iv, cartilage of Wrisberg lying 
in the fold of membrane which extends from the summit of the arytenoid, on 
either side, to the epiglottis, g a, tubercle which sometimes exists between the 
cartilage of Santorini and Wrisberg. u st, inferior, or true vocal cords, o st, 
superior, or false vocal cords, v M, the depressions between them, leading to 
the ventricles of the larynx, a e, aryteno-epiglottic ligament, lying in the 
aryteno-epiglottic folds of mucous membrane, u I, rings of trachea, id, bs, 
right and left bronchus. (Czermak.) 

rounded ridges, and if the patient be directed to ejaculate " ah !"' they 
are seen to approximate closely, and then, during inspiration, to become 
widely divergent. The movements are vibratile, and very rapid. 

When the fauces are very irritable, a few drops of chloroform may 
be inhaled. In some nervous subjects two or three sittings may be 
required before a view of the glottis can be obtained. 

Causes of Aphonia. — These may be functional or organic. 
1. Functional aphonia is caused by paralysis or excessive debility of 



Fir. 60. 



Fig. 61. 




Oedema of the glottis, the superior vocal Partial loss of the epiglottis (sy- 
cords a a, and the aryteno-epiglottidean philitic) and swelling of false 
folds much swollen, the former almost vocal cords. Symptoms, hoarse- 
meeting over the true vocal cords. ness, passiDg into aphonia. (Czer- 
mak.) 

the muscles of the larynx, as in cerebral apoplexy, diphtheria, cholera. 
Hysteria is a common cause of aphonia, but in this disease there is not 



APHONIA — TREATMENT. 



451 



a loss but a suppression of voice, and the patient may talk in her sleep, 
or be induced to do so under the influence of electricity. Severe fright 



Fig. 63. 




a a, the true vocal cords, below which are Polypus attached to the right vocal 

two sub-glottic swellings, meeting in the cord, the real cause of a supposed 

centre. 5, epiglottis, c c, arytenoid nervous aphonia. (Czermak.) J 
cartilages, d, back of tongue. (Gibb.) 

occasionally causes temporary loss of speech. In all cases of functional 
aphonia the vocal cords lie almost parallel, separated by a variable in- 
terval, and immoveable. 

2. Organic aphonia. — The causes of organic aphonia are the follow- 
ing: — Laryngitis; osdema; chronic thickening ; ulceration; tubercular 
deposits ; cancerous, warty, or cystic tumours, of the vocal cords or 
arytenoid cartilages ; abscesses or other tumours of the contiguous parts 
projecting between the vocal cords, or pressing on them. The margin 
of the glottis is a very favourite seat for warty excrescences. 

Treatment. — Functional aphonia generally, and especially that 



Fig. 64. 



Fig. 65. 





Large epithelial tumour arising from the Syphilitic excrescences on true 

interior vocal cord, and occupying the vocal cords. (Condylomata of 

aperture of the glottis. Symptoms, hoarse- the larynx.) Symptoms, se- 

ness, followed by aphonia. (Czermak.) vere hoarseness. (Czermak.) 

caused by paralysis, will be benefited by electricity. In debility the 
general treatment recommended under diphtheria will be required. 



452 ceoup. 

Strychnia in i grain doses twice or thrice a day has proved serviceable 
in some cases. Astringent and stimulating gargles may be used simul- 
taneously. Hysterical aphouia requires the treatment of hysteria. The 
treatment of organic aphonia will vary with its cause. If there be tu- 
bercular infiltration, we may apply a leech over the thyroid cartilage 
occasionally, or direct croton liniment to be rubbed in ; the general 
treatment being that of phthisis. If there be follicular enlargement 
or ulceration, solution of nitrate of silver (gr. v in 5J) may be applied 
within the lips of the glottis by means of a camel-hair brush fitted in a 
handle suitably curved. Granular enlargements and chronic ulcerations 
may be removed by the repeated application of solid nitrate of silver. 
Malignant disease may be kept in check by the same means. Small 
pedunculated tumours may be removed by Dr. Gibbs's laryngeal ecra- 
seur. Abscesses and oedema may be relieved by a suitably curved bis- 
toury. 

Acute oedema requires very prompt treatment. When practicable, 
the cedematous part may be freely pricked here and there with a curved 
and fine-pointed armed bistoury, so as to induce free bleeding. If this 
operation cannot safely be performed, strong solution of nitrate of silver 
may be applied to the larynx and a few leeches to the throat ; and 
TT)_xxx tincture of perchloride of iron may be given. If no relief be 
afforded, and suffocation impend, tracheotomy must be performed. 



TRACHEITIS, or CYXAXCHE TRACHEALIS— THE CROUP. 

Symptoms. — The disease generally begins with hoarseness, wheezing, 
and a dry short cough. Sometimes there is a rattling in the throat 
during sleep, and the child is often observed to raise the hand to the 
throat. After a time the breathing becomes difficult, the voice husky 
or absent, and the breath is drawn in with an audible sound, as if 
passing through a constricted orifice or narrow tube, and in speaking or 
coughing, it acquires a shrill and peculiar sound, similar to the crowing 
of a cock. The cough is dry ; but at length a viscid matter is brought 
up, and flakes or tubes of false membrane, with efforts often so dis- 
tressing as to threaten strangulation. The disease is accompanied by 
inflammatory fever, with hot skin and flushed face, and generally ter- 
minates fatally about the second or third day ; the lips become blue, 
the pulse thready, and after much distress the patient becomes drowsy 
and comatose, and ultimately dies suffocated. 

Anatomical Characters. — Inflammation of the lining membrane 
of the trachea, often extending to the larynx and bronchi, and the for- 
mation of a false membrane, which, in extreme cases, fills the trachea 
and bronchi. Large portions of this false membrane, casts of the tube, 
have been expelled during fits of coughing and vomiting. 

Causes. — Remote and Predisposing, Age from three to fourteen ; 
low and damp situations, inland, or on the sea- shore. — Exciting. The 



LARYNGISMUS STRIDULUS. 453 

common causes of inflammation. The disease is sometimes epidemic, 
and some suppose it to be contagious. 

Diagnosis. — By the peculiar breathing, speaking, and coughing 
above described. From laryngismus stridulus. — See that disease. 

Prognosis. — Favourable. Early and free expectoration, the breath- 
ing not much impeded, the voice little changed, the febrile symptoms 
moderate. — Unfavourable. Great anxiety and difficulty of breathing, 
with shrill whistling inspiration ; livid face, and cold extremities. 

Treatment. — Indications. I. To subdue inflammation. II. To 
obviate urgent symptoms. 

I. The first indication is fulfilled by the free application of leeches 
to the larynx and trachea ; followed by a warm bath and tartar-emetic 
in nauseating doses. The treatment may be commenced by an emetic 
of from half a grain to a grain of tartar-emetic, according to the age. 
The bowels should also be freely opened. 

Calomel should be combined with the tartar-emetic, and mercurial 
ointment should be rubbed into the thighs or arm-pits, so as rapidly to 
affect the system, and prevent the further effusion of lymph. Mercury 
may be used with the more freedom in children, as they are with diffi- 
culty affected by it. 

II. If the symptoms are urgent, the false membranes may sometimes 
be brought up by the operation of an emetic. When partially discharged 
by coughing, they should be carefully removed by the hand. If suffoca- 
tion threaten, tracheotomy must be performed. To be successful, it 
should be performed as early as possible ; but it often fails through the 
extension of the inflammation to the lower part of the trachea, or even 
into the bronchial tubes. 



LARYNGISMUS STRIDULUS— FALSE or SPASMODIC CROUP, 

Synonyms. — Crowing inspiration ; child-crowing ; spasmodic 
asthma of children ; thymic asthma. 

Symptoms. — The principal feature of the disease is a remarkable 
crowing inspiration, unattended by cough, coming on suddenly, and 
often on first waking from sleep. For a short time the child makes 
ineffectual efforts to inspire air, and struggles violently, but at length 
the difficulty is overcome, and the breath is drawn in with a loud 
crowing sound. If the impediment be less complete, the respiration is 
hurried and laborious, each inspiration being attended by the peculiar 
crowing sound ; the face becomes livid, the eyes staring and suffused, 
convulsions supervene, the thumbs are clenched in the hands, the fingers 
and toes are flexed, and the joints of the wrist and ankle forcibly bent. 
In extreme cases, death takes place by asphyxia, or the little patient 
falls, pale and exhausted, into the nurse's lap. 



454 CATARRH. 

Pathology. — Irritation reflected through the inferior or recurrent 
laryngeal nerve on the muscles of the larynx, in consequence of irrita- 
tion of the gums, stomach, or bowels. A diseased condition of the 
bronchial and cervical glands, producing irritation of the pneumogastric 
nerve, or its recurrent laryngeal branches. 

Causes. — Predisposing. Infancy ; from birth to the age of three 
years ; the scrofulous diathesis. — Exciting. Teething ; intestinal irri- 
tation : worms ; enlargement of the glands of the neck and chest. 

Diagnosis. — From croup, by the sudden accession and departure of 
the fits ; by the freedom of the breathing in the intervals ; by the ab- 
sence of febrile or catarrhal symptoms ; and, except in rare cases during 
the fit, of cough. 

Prognosis. — The disease generally terminates favourably. Fatal 
eases are rare. 

Treatment. — During the fit. The patient should be placed in a 
warm bath, the face being exposed to a current of fresh air, and cold 
water should be dashed over the face and chest. If suffocation be im- 
minent tracheotomy must be performed. — During the intervals. The 
treatment must depend on the existing causes of irritation. If the 
disease continues when these are removed, change of air, a suitable diet, 
and attention to the state of the bowels, will generally effect a cure. 

Spasmodic diseases of the larynx, with croupy respiration, and con- 
vulsive cough or loss of voice, are of frequent occurrence in females, 
and belong to the long list of anomalous hysteric affections. They must 
be treated in the same way as other hysterical symptoms. 



DISEASES OF THE BRONCHIAL TUBES AND AIR-CELLS. 

Cataerhus Catarrh. 

Catarrhus Epedemicus . - Influenza. 

Bronchitis Bronchitis. 

Asthma Asthma. 

Emphysema Emphysema. 

Pertussis Whooping-cough. 

CATARRHUS— CATARRH. 

Acute catarrh, commonly called "a cold/' is a febrile affection, 
complicated with inflammation of one or other of the mucous mem- 
branes, If confined to the mucous membrane of the eyes and nostrils, 
it is called coryza, or a cold in the head ; if it ex tend to the bronchial 
tubes, it is termed bronchitis ; if it attacks the mucous membrane of 
the bladder, it becomes a catarrhus vesicas. Sometimes the inflamma- 
tion affects the mucous membrane of the alimentary canal, and is 
attended with sickness and diarrhoea, or both, assuming the form of 



CATARRHUS EPIDEMICUS. 455 

gastritis, enteritis, or gastro-enteritis mucosa. Its essential characters, 
therefore, are increased secretion of mucous from the nose, fauces, 
bronchi, intestinal canal or bladder, and pyrexia. 

Symptoms. — Slight rigors followed by pyrexia ; weight and pain in 
the head ; oppression of the chest, and impeded respiration ; sense of 
fulness and obstruction in the nose ; repeated sneezing ; watery inflamed 
eyes ; cold shiverings, succeeded by transient flushes of heat ; soreness 
of the fauces and tonsils ; herpetic eruptions on the lips ; cough ; pains 
about the chest ; rheumatic pains in the back, neck, and head. After 
an interval of time, increased secretion of mucous from the affected 
mucous membrane. The chronic form of the disease is exemplified in 
common bronchitis. 

Diagnosis. — The absence of bronchial, pneumonic, and pleuritic 
symptoms. 

Causes. — Cold, or wet and cold, applied to the body. 

Treatment. — In most cases the best treatment of a cold is by ten 
grains ot Dover's powder given over night, followed by a warm bath, or 
warm water to the feet, a basin of warm gruel, and a hot bed. By 
these means a profuse perspiration is excited, which effectually removes 
the febrile action. The Dover's powder may be followed up next 
morning by a saline aperient. A drachm of spiritus chloroformi may 
be substituted for Dover's powder. A large draught of cold water, 
taken at bed- time, will often effectually remove a common cold. If the 
fever run high, the best remedy is tartarized antimony in nauseating 
doses and at short intervals, with cooling drinks and saline purgatives. 

If there be much smarting and running at the eyes, relief may be 
obtained by holding the head over the steam of hot water, or bathing 
the eyes repeatedly with warm water. 



CATARRHUS EPIDEMICUS— INFLUENZA. 

Symptoms. — Those of a common cold in their most marked form, 
with sudden and extreme prostration, loss of energy, and depression of 
spirits. The febrile symptoms, which generally assume a remittent 
type, do not run high, nor is the pulse much increased in frequency. 
Sometimes the catarrhal symptoms are very slight, the disease being 
characterised by extreme debility without local symptoms. 

Terminations and Complications. — Pneumonia tonsillitis bron- 
chitis and pleurisy are often intercurrent. Muscular and articular 
rheumatism ; diarrhoea and dysentery ; erysipelas ; continued fever ; 
occasional sequences. 

Causes. — Predisposing. The male sex ; adult and especially old 
age ; a former attack ; low, damp situations. — Exciting, A peculiar 
condition of the atmosphere. 



456 BRONCHITIS. 

Laws of the Epidemic. — The influenza has been epidemic in the 
years 1510 and 1557; in 1729, 1733, 1743, 1762, 1775, and 1782; 
in 1830, 1837, 1841, 1844, 1847, and 1851. It seems to have ori- 
ginated in the East, and after an uncertain period to have shown itself 
in the north of Europe, whence it has spread westward till it reached 
England ; and from England has passed in a south-easterly direction to 
France, Spain, and Italy, and across the Atlantic to America. Its 
course is very similar to that of the Asiatic cholera, of which it has 
more than once proved the precursor. Australia has been visited in 
recent epidemics. The disease, in every epidemic, has attacked a very 
large proportion (estimated at three- fourths, four-fifths, and nine- 
tenths) of the population, as well as many of the domestic animals. 
The mortality occasioned by it is considerable. In a million inhabitants 
of the metropolis the registered deaths from influenza were 65 in 1844, 
117 in 1841, 150 in 1851, 295 in 1848, and 572 in 1847. In a recent 
year the total deaths in the metropolis from this cause were 1253. Its 
latent period is believed to be from a few hours to two or three weeks. 
It commonly remains in the same district or country from a month to 
six weeks. 

Diagnosis. — From common catarrh, by its greater prevalence, the 
suddenness of its attack, the extreme debility which attends and follows 
it, and by its occurring indifferently at all seasons of the year, and in 
all states of the atmosphere. From ephemeral fever, by the extreme 
prostration, and, in many cases, by the herpetic eruption on the lips. 

In the epidemic of 1844—5, several cases of influenza assumed a 
well-marked remittent character, with exacerbations on alternate days, 
and the herpetic eruption on the lips. (G.) 

Prognosis. — Rarely fatal to the young tmd robust, unless compli- 
cated with pneumonia ; dangerous to the aged, to the feeble, and the 
intemperate, and to persons subject to asthma and consumption. 

Treatment. — In mild cases, that of catarrh ; in severe ones, and in 
aged persons, stimulants, combined with opiates (Form. 119, 238), with 
a nourishing diet, and liberal use of wine, and local treatment appro- 
priate to the existing complication. In the treatment of local compli- 
cations, the adynamic character which they assume in influenza must 
be borne in mind. Change of air is one of the best remedies as soon as 
the severe symptoms have passed away. 



BRONCHITIS. 



Varieties. — 1, Acute. 2. Chronic. 3. Plastic (Bronchial 
Polypi). 

1. acute bronchitis. 

Symptoms. — Bronchitis often supervenes upon severe catarrh, the 
inflammatory affection of the mucous membranes spreading from the 



ACUTE BRONCHITIS. 457 

upper part of the respiratory tract into the lungs. The general 
symptoms are severe in proportion as the mucous inflammation extends 
towards the air lobules. The skin is hot and dry, the pulse full and 
rapid ; there is more or less urgent dyspnoea with wheezing inspiration, 
and a sense of great oppression referred to the epigastrium. The patient 
is exhausted by a dry wheezy cough, which often comes on in severe 
paroxysms ; the head is hot and painful, the tongue coated, the urine 
scanty and high-coloured, and deposits lithates. 

After a few days the cough becomes moister, and a clear viscid 
frothy mucus is expectorated. This gradually loses its adhesiveness 
and becomes thick and purulent ; free expectoration now sets in, afford- 
ing much relief, the lever and dyspnoea subside, and the cough alone 
remains. At first it is so frequent that little continuous sleep can be 
obtained ; in a few days the expectoration begins to diminish, the cough 
subsides, and the patient convalesces. The mucous membrane, how- 
ever, recovers but slowly, and it often remains in a congested, debili- 
tated condition, and liable, on the least change of temperature, to 
renewed attacks of inflammation, which ultimately become chronic. 

When the inflammation spreads into the vesicular structure, and be- 
comes diffused through both lungs, the symptoms are very urgent, the 
dyspnoea extreme, the face dusky and anxious. 

The local signs of the disease are highly characteristic. The sitting 
posture is chosen to allow of the free expansion of the chest, the arms 
and head are firmly fixed to give effect to the action of the extraordinary 
muscles of inspiration ; the chest is everywhere resonant ; on applying 
the ear, the air is heard, during inspiration, to traverse the bronchial 
tubes with a wheezing, wind-sighing, or whistling sound ; and, during 
expiration, to pass back again with a prolonged sonorous rhonchus. 
These sounds are loudest about the roots of the lungs, i.e., about the 
middle parts of the chest in front and behind. At the bases, apices, 
and sides the vesicular murmur may still be heard, but feebler than 
usual, and here and there obscured by the coarser morbid sounds, or its 
place is supplied by crepitation. The rhonchus and sibulus are often 
so loud and general that the vesicular murmur is nowhere heard. 

While the inflammation prevails, the elasticity of the lungs is more 
or less impaired, and in some severe cases the air is imprisoned in the 
distended lobules by the inflamed and constricted smaller tubes. In 
this condition the dyspnoea is extreme ; we hear dry, wheezing, and 
rhonchial sounds, but no vesicular murmur. 

As soon as secretion begins moist sounds are heard. If the inflam- 
mation have involved the finer air tubes and the vesicular structure, a 
fine mucous crepitation is heard over the whole of the back and sides of 
the chest ; and in the larger tubes coarser crepitation or mucous rales, 
with more or less musical wheezing. During an attack of acute bron- 
chitis, the ingress of air to an entire lobe of one of the lungs may be 
suddenly stopped. During a violent fit of coughing, the tenacious 
mucus brought together from the smaller tubes is drawn back into a 
large bronchus by the forcible inspiration which accompanies the con- 
vulsive cough, and becomes firmly impacted. The symptoms are 



458 CHRONIC BRONCHITIS. 

sudden and extreme dyspnoea, or actual suffocation. No air is heard 
to enter that part of the lung to which the obstructed bronchial tube 
leads, but, since it is distended with imprisoned air. the corresponding 
part of the chest retains its natural resonance. 

Acute bronchitis often occurs in children; its most severe and 
urgent form has received the name of suffocative catarrh, and is cha- 
racterised by a sudden and copious secretion of mucus, extreme and 
urgent dyspnoea, and fine mucous crepitation in every part of the lungs. 

2. CHRONIC BRONCHITIS. 

Symptoms. — This disease is the sequel of the acute form. In middle- 
aged or old persons it returns every winter with increased severity, 
and reappears for several years in succession ; in which case it is called 
winter cough. When the mucous membrane secretes freely, and the 
breathing is very difficult, the disease is called humoral asthma. The 
symptoms of this disease are habitual cough, shortness of breath, and 
copious mucous expectoration. After repeated attacks of the disease, 
the pulmonary tissue becomes weakened, and emphysema results, 
marked by increased dyspnoea, and a peculiar dusky hue of countenance. 
The sufferings of the patient are often increased by flatulence. 

In advanced age there are drowsiness, extreme and increasing debility, 
and coldness of the surface, and the patient is at length suffocated 
by the accumulated mucus, which he has no longer strength to ex- 
pectorate. 

Dilatation of the bronchial tubes frequently accompanies chronic bron- 
chitis. The symptoms are broncorrhcea, dyspnoea, unusual resonance of 
the chest, with tracheal or even amphoric breathing. Gurgling and 
pectoriloquy may also be heard if the dilatation be considerable. The 
excessive expectoration leads to wasting of the body. 

Morbid Anatomy. — Swelling and redness of the tracheal aud 
bronchial mucous membrane, observed most commonly at the termina- 
tion of the trachea, and in the first divisions of the bronchi. The air- 
passages contain a large quantity of tenacious mucus, or muco-purulent 
fluid. Portions of the lungs are occasionally collapsed. Collapse may 
be diffuse or scattered. Diffused collapse may affect the whole lobe of 
a lung. When it is complete, the part has the colour and consistence of 
foetal lung, containing little blood, and being pale. The scattered form 
of collapse affects only single lobules or small aggregations of lobules, 
and usually those situated in the anterior edges of the lungs. The 
collapsed lobules form little depressions like cicatrices, usually of a dark 
colour. Collapsed lung may be readily inflated, and is thus distin- 
guished from consolidated lung. The mechanism of collapse is veiy 
simple. A plug of mucus is drawn by a forcible inspiration into a 
bronchial tube ; the contraction of that portion of the lung to which 
the obstructed tube leads may dislodge the plug sufficiently to allow 
the passage of air in expiration ; but on inspiration it is again drawn 
back. The plug thus acts as a valve, allowing of the egress, but pre- 



PLASTIC BRONCHITIS. 459 

venting the ingress of air, until at last the obstructed lung is com- 
pletely deprived of air. The chest being an air-tight cavity, collapse 
of one part of the lung must be complemented by dilatation (emphy- 
sema) of another, and thus one morbid condition generates another. 
Emphysema alone is the commonest result of long-standing bronchitis. 
Dilatation of the bronchi is another morbid condition often found in 
chronic bronchitis ; the tubes may be uniformly enlarged for a distance, 
or they may present spindle-shaped, globular, or saccular dilatations 
here and there, and the dilated part of the tube may be very thin ; but 
usually its walls are greatly hypertrophied. The dilatation is due to 
atrophy, or abscess of the lung-tissue in the neighbourhood of the larger 
bronchi, the dilatation being complementary. 

3. PLASTIC BRONCHITIS (BRONCHIAL POLTPl). 

Symptoms. — Plastic bronchitis is known by the expectoration of 
branched fibrinous casts moulded in bronchial tubes of the third or 
fourth diameter. Sometimes the casts are hollow and shreddy, but 
more usually they are solid and compact. The disease is always 
associated with haemoptysis. It recurs after variable intervals. The 
physical signs are dulness almost as complete as in pneumonia, and ab- 
sence of breath as well as voice-sounds, in the affected portion of the 
lung, by which the disease is distinguished from pneumonia. 

Pathology. — Croupy, fibrinous exsudations from the mucous mem- 
brane, the detachment of which occasionally leads to hemorrhage and 
the formation of coagula, which may take the form of the tubes. 

PROGNOSIS. — The disease is rarelv fatal, but it is verv obstinate. 



Diagnosis. — Bronchitis occupying the whole of both lungs, occur- 
ring in a young adult of either sex, and not speedily yielding to treat- 
ment, justifies a suspicion of miliary tubercles. Chronic bronchitis 
with broncorrhoea and dilatation of the bronchi may, at rirst sight, be 
mistaken for phthisis. The broncorrhoea accompanying dilated bronchi 
may cause emaciation, and give rise to tracheal breathing and pectori- 
loquy. But the history of the case, the nature of the expectoration, 
and the other physical signs, will furnish decisive evidence of the nature 
of the disease. 

Sequels. — Emphysema, hypertrophy of the heart, and dropsy. 

Prognosis. — Generally favourable in the acute and chronic forms : 
guarded in bronchitis senilis. 

Causes. — Exposure to cold, the rheumatic and gouty diatheses, 
heart and renal diseases. In children, measles and whooping-cough. 

Treatment. — Of acute bronchitis. In very acute attacks, occur- 
ring in persons previously in strong health, general bleeding from the 
arm, followed by tartar-emetic in nauseating doses, may be necessarv ; 
blisters, mustard poultices, or turpentine stupes, may be applied to the 



460 ASTHMA. 

chest. The general treatment of bronchitis consists in the exhibition of 
stimulating expectorants, such as a combination of ammonia, squill, and 
senega. Free sweating and diuresis should be induced by appropriate 
medicines. When the expectoration is freely established, we may give 
squill or ipecacuanha in combination with the mineral acids. If the 
circulation be feeble, we may give a moderate amount of gin or brandy. 
If hypnotics be required, we must use henbane in combination with 
opium. Opium alone must be given, carefully and rarely prescribed, 
in the early stages of the acute disease. The plastic form of bronchitis 
is not very amenable to treatment. In otherwise healthy persons it 
gradually subsides. Tt\xx tincturse ferri perchloridi, and the inhalation 
of the vapour of turpentine, are the remedies most likely to do good. 
As a prophylaxis, the patient should never remain in a heated atmo- 
sphere. In the bronchitis of children, emetics are very serviceable by 
promoting expectoration. 

In the chronic form of bronchitis, the treatment must be nearly the 
same as in the milder form of the acute disease. Compound squill pill 
is an excellent remedy, and it may be combined with comp. ipecac, 
powder or the extract of conium. When there is a considerable collec- 
tion of mucus in the air-tubes, with urgent dyspnoea, an emetic may 
be given early in the morning, or twice in the week, with the greatest 
advantage. The body should be kept warm, and the chest may be 
protected by a full-sized emplastram picis. The balsams, gum resins, 
and oleo-resins, such as myrrh, benzoin, tolu, ammoniacum, galbanum, 
copaiba, and turpentine, often do much good. 

In old age. — When the debility is extreme, the appropriate remedy 
is a combination of stimulants and narcotics (Form. 235, 239). A 
nourishing diet and a liberal allowance of wine are also required. When 
dropsical effusions supervene, diuretics and expectorants must be given 
in combination with stimulants. The body and extremities should be 
kept warm, and exposure to cold avoided. The rooms should be kept 
warm, and as nearly as possible of an uniform temperature night and 
day. On leaving the room during the winter, a respirator should be worn, 
or, what answers nearly as well, a folded handkerchief held before the 
mouth. In many cases, exposure to cold air gives temporary relief, 
but the symptoms return with renewed severity when the circulation is 
restored by the warmth of the room. 



ASTHMA. 
Definition. — Paroxysms of dyspnoea, with intervals of freedom. 

Species. — 1. Humoral asthma. 2. Congestive asthma. 3. Spas- 
modic asthma. 4. Hay asthma. 5. Hysteric asthma. 

1. Humoral Asthma. — Bronchorrhcea, or bronchial flux. 

Symptoms. — The attack is usually preceded by a sense of fulness 



HUMORAL ASTHMA. 461 

at the pit of the stomach, lassitude, depression of spirits, drowsiness, 
and pain in the head ; followed, on the approach of evening, by a sense 
of tightness across the breast, and dyspnoea, which continues to increase 
for some length of time. Both inspiration and expiration are performed 
slowly, and with a loud wheezing noise, and there is a dry cough. The 
face is either turgid and livid, or pale and contracted. At length the 
difficulty ot breathing becomes so great that the patient, threatened 
with suffocation, leaves his bed, paces up and down his room, stands in 
a stooping posture, or sits with the body bent forwards, the arms 
resting on the knees, the shoulders raised, the abdomen contracted, and 
all the muscles of respiration thrown into violent action ; and still 
finding no relief, seeks at the open window a supply of cold air. These 
symptoms usually continue till the approach of morning, when a 
copious expectoration of a thin frothy mucus comes on, the breathing 
becomes less laborious and more full, the patient speaks and coughs 
with greater ease, and, feeling every way relieved, falls asleep. The 
dyspnoea and tightness of the chest, with evening exacerbations, remain 
for some days. The attack often comes on about midnight. 

Physical Signs. — Sound on percussion generally good. Sonorous 
and sibilant rhonchi at the commencement of the attack, followed by 
the mucous rale and crepitation. Some wheezing and sibilus usually 
remain after the attack. 

Morbid Anatomy. — The mucous membrane is generally free from 
disease ; but some affection of the heart, particularly of the right side, 
is not uncommon. Emphysema is common in this, as in the other 
forms of asthma. 

Causes. — 'Predisposing. Hereditary peculiarity ; lax habit of body ; 
long-continued dyspepsia; gout. — Exciting. Sudden changes ot tem- 
perature ; disorders of the alimentary canal, especially flatulence ; 
certain effluvia, as of hay or ipecacuanha. 

Diagnosis. — From other diseases affecting the respiration, by the 
distinct paroxysms with intervals of perfect freedom. From congestive 
and spasmodic asthma by the copious secretion which ends the fit. 

Prognosis. — Asthmatic patients often attain to an advanced age, and 
the prognosis is favourable when tendency to phthisis and organic 
disease of the heart are absent. 

Treatment. — I. Immediate. An emetic at the onset of the attack, 
if the patient is strong enough to bear it. In vigorous persons full 
doses of tartar-emetic, of ipecacuanha, or of the lobelia inflata (TY^xv 
to 33 of the sethereal tincture) may be given with great advantage. In 
the weak, stimulants are required, such as strong coffee, ammonia, or 
3ether. These may be combined with opium in moderate doses. Heat 
applied to the extremities, or to the entire surface, by means of the warm 
or vapour bath, is extremely serviceable at the onset of the attack. 
When the fit has already lasted some time, and the expectoration is 
abundant, it may be encouraged by inhalations of conium. 



462 ASTHMA. 

II. Subsequent. — The exciting causes must be carefully avoided, the 
general health improved, and the digestive organs carefully regu- 
lated. The bowels to be kept free, but hypercatharsis avoided ; liquids 
should be taken in moderation ; the diet should be plain, the meals 
light, and acescent fruits and such vegetables as occasion flatulence be 
avoided. The internal remedies will vary with the state of the system. 
Astringent tonics are serviceable in most cases. 

I have found alum, combined with ginger, very serviceable in 
removing the distressing flatulence which often precedes and accom- 
panies the fit. Ten grains of the one, with five erains of the other, and 
three or four grains of rhubarb, may be given three or four times a day. 
I have also more than once met with spinal tenderness in the cervical 
and dorsal regions, and have used tartar- emetic ointment with much 
benefit. (G.) 

2. Congestive Asthma. — Dry Catarrh. 

This, like the foregoing, comes on in paroxysms of severe dyspnoea, 
but differs from it in the scanty expectoration that attends the cough, 
and terminates the fit. The sputa are scanty, highly adhesive, filled 
with air-bubbles, and speckled with round black or grey spots, and, at 
the height of the fit, often tinged with blood. After a time they be- 
come more abundant and less tenacious, and the fit passes off with 
increased expectoration. 

Physical Signs. — Those belonging to a swollen state of the mucous 
membrane of the air-tubes — viz., clear sound on percussion, indistinct 
respiratory murmur, with sibilant rhonchi, or a peculiar click, and, in 
limited portions of the chest, the mucous crepitation. 

Morbid Anatomy. — A deep red or violet colour of the mucous 
membrane of the air-tubes, with scanty mucous secretion. 

Causes. — Those of humoral asthma. Valvular disease of the heart. 

Prognosis. — Generally favourable, except when of long standing, or 
complicated with other functional or organic diseases. 

Treatment. — Nauseating expectorants, as tartar-emetic, squills, 
ipecacuanha, lobelia inflata, are indicated in this foim of the disease, 
together with inhalations of steam, tar-vapour, ammonia, and conium. 
Dry cupping and counter-irritation to the chest may be practised with 
advantage. Smoking stramonium is sometimes found advantageous, as 
in spasmodic asthma. Strict attention must be paid to the digestive 
organs ; the bowels must be kept free by aloetic purgatives, and the 
general health be carefully attended to. 

3. Spasmodic Asthma. — This term is applied to dyspnoea occurring 
in fits, unaccompanied by signs of congestion or inflammation of the 
bronchial tubes, and presumed to depend on spasm of the muscular 
fibres of the air-tubes. 

Symptoms. — Those of humoral asthma ; but that the fit comes on 
more suddenly, and terminates without expectoration. 



HYSTERIC ASTHMA. 463 

Physical Signs. *— Sound on percussion less clear than usual, respi- 
ratory murmur very faint, aud occasionally accompanied with slight 
wheezing or whistling. If the patient be desired to hold his breath for 
a few seconds, or to count till the air in the chest is exhausted, and 
then to inspire slowly and steadily, the air will be heard to enter as 
usual. The respiratory murmur soon becomes feeble again. 

Causes. — Predisposing. The same as in other spasmodic diseases ; 
hereditary peculiarity ; hysteria. — Exciting. Attacks of dyspepsia ; 
extreme flatulence ; irritation of the upper part of the spinal cord ; 
pressure of turnout's on the pulmonary plexus or on the vagus. 

PROGNOSIS. — Favourable in the absence of complications : dangerous 
when combined with other diseases of the lungs, or with those of the 
heart. It often causes pulmonary congestion, and haemorrhage, and 
induces emphysema, and dilatation and hypertrophy of the heart. 

Treatment. — I. When the fit has actually commenced, some relief 
may be arlbrded by counter-irritants to the chest, epigastrium, and 
extremities ; by antispasmodics, as opium, aether, chloroform, bella- 
donna, assafcetida, aud valerian. Opium and aether in combination 
(tr. opii. TY\xx to 5ss, and aether 5ss to 3i) is a useful remedy in the 
fit. When the patient is aware of the approach of a fit, he may some- 
times ward it off by an emetic, or by smoking stramonium or tobacco. 
Dashing cold water over the face and body will often succeed in prevent- 
ing a paroxysm. The ascertained causes of the fit must be carefully 
avoided. 

II. The diet should be light, wholesome, and easy of digestion ; and 
all substances which encourage flatulence should be avoided. The state 
of the bowels must be carefully attended to. For the improvement of 
the general health, the shower-bath, or cold sponging, followed by 
frictions of the chest every morning ; and tonics. Where much flatu- 
lence is present, alum in combination with ginger may be given with 
advantage. If there be tenderness in any part of the spine, leeches may 
be applied, or the tartar-emetic ointment, or both. 

When the spasm of the bronchial tubes is combined with congestion 
of the mucous membrane, or with increased secretion, depletion or 
counter-irritation must be employed with antispasmodic remedies. 

4. Hay asthma. — Hay Fever. 

Symptoms. — Those of humoral asthma, with the addition of marked 
symptoms of catarrh. 

Causes. — Predisposing. Peculiarity of constitution. — Exciting. The 
odour of hay, or that of a stable. In some cases fine powder floating 
in the air, e-pecially that of ipecacuanha. 

Treatment. — That of humoral asthma during the paroxysm. In 
the interval, the caieful avoidance of the exciting cause. 

5. hysteric asthma. 
Symptoms. — This disease has its seat in the external muscles, and is 
closely -allied to chorea and hysteria. It is characterised by extraordi- 



464 EMPHYSEMA. 

nary frequency of the respiration, with perfectly healthy sound of the 
chest and breathing ; and a rapid pulse. Sometimes also it is a marked 
symptom of paralysis agitans, the muscles of respiration partaking of 
the agitation. 

A remarkable case of spasmodic asthma in a female aged twenty-two, 
came under my notice several years ago. The fits, which were of vari- 
able duration, were characterised by extreme frequency of breathing, 
with comparatively little general disturbance of health. There was 
amenorrhcea, some tenderness of the upper part of the spine, and consti- 
pation. The disease was cured by purgatives carefully and perseveringly 
administered. Xo other remedy was applied. Hypercatharsis was in- 
variably followed by a paroxysm. In a case of the same kind in which 
there were 140 respirations to 144 pulses. Much benefit was derived 
from cold affusion. (G.) 



EMPHYSEMA. 



Symptoms. — Permanent shortness of breath, increased to extreme 
dyspnoea by occasional exciting causes, such as exercise, flatulence, or a 
common cold ; and in extreme cases, by assumiDg the horizontal posture ; 
with a dusky hue of countenance and cold extremities. Fits of orthopncea, 
with a violent palpitation and blueness of the face and lips, come on sud- 
denly in the night, obliging the patient to sit up, and to open the doors 
and windows of his room for air. The dyspnoea is attended by cough, 
with scanty expectoration, which varies in character, consisting in most 
cases of a thin mucus, mixed with small tenacious clots, and filled with 
air-bubbles. The expectoration is often increased by a supervening 
attack of bronchitis ; and it becomes abundant towards the end of the 
fit. In cases of long-standing the general aspect of the body undergoes 
a change ; the face becomes pale, and of a dusky hue, the body grows 
thin, and the legs and abdomen swell. 

Physical Sig-xs. — Peculiarly clear sound on percussion, extending 
lower than usual ; indistinct respiratory murmur, and prolonged inspi- 
ratory and expiratory sounds ; and, in some cases, a dry crepitation, 
with occasional loud clicking sound, or a friction sound, similar to 
that of a finger rubbed on a table. The respiratory movements 
are indistinct, and the respiration is abdominal. The impulse of 
the heart is best felt in the epigastrium ; the natural precordial dulness 
has disappeared. In marked cases, the chest bulges in all directions ; 
but when the emphysema is confined to one lung, or to a part of one 
lung, it is irregularly enlarged. It is usually associated with bronchitis. 

Morbid Axatomy. — Distension of the lungs; the anterior margins 
almost meet and conceal the pericardium ; the heart and diaphragm are 
depressed ; usually there are extensive old adhesions between the pleurae, 
and the cartilaginous ribs are ossified. The lungs are pale, dry, and 
bloodless, and have a soft woolly feel ; their cells are enlarged ; and the 



PERTUSSIS. 465 

distended lobules are often ruptured and communicate with each other, 
forming little bladders which collapse on the lightest touch of the 
scalpel. These are usually found on the thin anterior margins of the 
lungs. Hypertrophy with dilatation of the right side of the heart. 
General venous congestion. 

Sequels. — The permanently distended condition of the air-cells, 
opposing as it does the entrance of a proper quantity of blood into the 
lungs, ultimately produces hypertrophy of the right side of the heart. 
Fatty degeneration of the liver and kidneys. Anasarca and ascites. 

Diagnosis. — From asthma, by the permanent shortness of breath. 
But as emphysema is common in chronic bronchitis, and supervenes 
after repeated attacks of all the forms of asthma, this diagnostic mark 
can rarely be applied. 

Causes. — Repeated attacks of bronchitis, impairing the contractility 
and elasticity of the air-cells. Pleuritic adhesions, preventing the con- 
traction of the lungs. Old age, leading to degeneracy of the lung- 
tissue. 

Prognosis. — The disease is rarely fatal in itself, but ultimately leads 
to dropsy. 

Treatment. — I. During the paroxysms. — The fits may be greatly 
relieved by opium and diffusible stimulants. From TT\ xx to 3ss of 
laudanum, with from half a drachm to a drachm of aether, may be ad- 
ministered at the onset. The shoulders should be well raised, the doors 
and windows thrown open, and the body, especially the lower extremi- 
ties, kept warm. In extreme cases, cupping between the shoulders, 
or the cautious abstraction of blood from the arm by a small orifice, 
may be necessary. When the patient has reason to expect an attack, an 
emetic, by emptying the stomach, and removing flatulence, may prevent 
the paroxysms ; and similar relief is sometimes afforded by the free 
action of a calomel and colocynth pill, followed by a black draught. 

II. During the intervals. — This disease does not admit of cure. The 
treatment consists in attending to the complications which may exist 
with it, and in a few simple precautions, such as the avoidance of colds 
by warm clothing and dry feet, the daily use of cold sponging or the 
shower-bath, regular and moderate meals, and aloetic aperients. If 
flatulence exist (Form. 282), food easy of digestion, and liquids in small 
quantity taken daily an hour before dinner. 

Emphysematous patients suffer most in close, moist weather, when 
the function of the skin is impeded ; and least when the weather is open 
and the air dry and bracing. 



PERT USSIS— WHOOPING-CO UGH. 

Synonyms. — Tussis convulsiva, chin-cough, kinkhost. 

Definition. — A contagious and infectious malady, characterised by 
a peculiar cough occurring in fits terminated bv vomiting. 

2 H 



466 PERTUSSIS. 

Symptoms. — The disease generally begins as a common cold, and it 
is not till after two or three weeks, or, in rare cases, as many months, 
when the febrile symptoms have somewhat abated, that the characteristic 
symptoms show themselves. The cough now comes on in distinct fits, 
consisting in a series of violent and convulsive expirations with conges- 
tion of the face, and threatening of instant suffocation, and sometimes 
with involuntary discharge of the urine and feces, followed by a sudden 
long-drawn inspiration, accompanied by a peculiar whoop which gives 
the disease its name. The convulsive coughing is renewed, and con- 
tinues as before, till a quantity of mucus, thrown up from the lungs, 
issues from the mouth and nostrils, perhaps mixed with blood ; or till 
the contents of the stomach are discharged by vomiting. After the fit 
the patient has an interval of perfect freedom from cough, and often 
expresses a desire for food ; but when the attack has been severe, it is 
succeeded by much fatigue, hurried respiration, and general languor 
and debility. Children evince great fear of the fits, and will run to 
their nurses or mothers for relief. Adults are seized very suddenly, 
and the paroxysms are usually very severe. The disease generally 
attains its greatest severity at the end of the fourth or fifth week, after 
which the paroxysms become less severe, and at length, after a further 
variable period of from two weeks to four months, entirely cease. In 
some instances, however, the disease is protracted for several months, 
and even for more than a year. 

Sequelje and Complications. — Bronchitis, with collapse of the 
lung: Pneumonia: Pleuritis: Gastritis: Phrenitis: Convulsions: 
Apoplexy: Epilepsy. 

Morbid Anatomy. — Inflammation of the bronchial tubes, with 
large collection of mucus in the air-passages. Collapsed spots, diffused 
or scattered, with complementary emphysema. Pneumonia. Inflamed 
bronchial glands. Inflammation of the mucous membrane of the 
stomach, and intestines, with enlargement of Peyer's and Brunner's 
glands. In other words, an inflamed condition of the parts supplied by 
the eighth pair of nerves, which have themselves been observed to be red. 

Causes. — Predisposing. Childhood. Adults, however, are not 
exempt ; and the disease may attack persons of seventy and eighty 
years of age. The seasons of spring and autumn. — Exciting. A 
specific poison acting on the eighth pair of nerves. 

Diagnosis. — In the early stage by the abundant sputa, the occasional 
vomiting, the violence of the paroxysms, and the perfect freedom in the 
intervals. When fully established, the convulsive cough and peculiar 

whoop above described. 

Prognosis. — Favourable. In proportion as the fits and bronchial 
inflammation are mild. — Unfavourable. A severe form of the disease in 
children under two years of age, and especially while suckling or teeth- 
ing; and in children born of phthisical or asthmatic parents. Compli- 
cation with diffuse bronchitis. 






PNEUMONIA. 467 

Laws of Infection. — Rarely attacks the same person twice. May 
coexist with small-pox, measles, and other febrile disorders ; but is 
sometimes cured on their appearance. Latent period, five or six days. 

Mortality". — The deaths in London during 15 years, in a million 
persons of all ages, fluctuated between 582 and 1217; average, 857. 
Two diseases only (^Typhus Fever and Scarlatina) are more fatal to 
life. 

Treatment. — 1. In the early stage tartarated antimony in doses 
sufficiently large to produce nausea. From a twelfth to a sixth of a 
grain, according to the age of the patient, may be given at short inter- 
vals, either alone, or in combination with a grain of hydrargyrum e 
creta. Occasional gentle aperients, a bland farinaceous diet, and the 
patient must be carefully guarded from cold, and kept in a pure warm 
air. When there is extreme restlessness, and great distress in the 
fits, the tartar-emetics may be combined with opium. Half an ounce 
of antimonial wine with a drachm of laudanum, and distilled water in 
sufficient quantity to make a mixture of ^iss, is a very good combina- 
tion. The dose, for a child of ten years old, may be a tea-spoonful 
twice or thrice daily. When the mucus is brought up with difficulty, 
an emetic should be given once, twice, or thrice a week. A warm bath 
should be given occasionally. 

2. If there be signs of inflammation in the lungs, a few leeches may 
be applied over the upper part of the sternum, followed, if necessary, 
by bread and mustard poultices, stimulating embrocations, or even 
blisters to the chest. If there be determination of blood to the head, 
leeches to the temples and cold applications. If the child be too weak 
to bear antimony, give ipecacuanha or squills in combination with 
spirit of chloroform and belladonna. Expectorants combined with 
mineral acids often do much good. When the severity of the disease 
has passed away, change of air is the best restorative ; and it is some- 
times of the greatest service in the height of the disorder. Debility 
must be treated by tonics, especially the preparations of steel. 

Remedies. — Sedatives, tincture or extract of hyoscyamus, or conium ; 
syrup of poppies ; extract of lettuce ; prussic acid ; belladonna ; digi- 
talis. — Antispasmodics, musk, garlic, assafcetida, and camphor ; cochi- 
neal, oil of amber, cantharides, cinchona bark. — Alteratives, arsenic 
sulphate of zinc, alum, bromide of potassium. To most of these 
remedies the following observations of Dr. Bateman may be applied : — 
" Perhaps there is no disease for which so many specifics and infallible 
nostrums are promulgated with confidence, or so few actual remedies 
known." 



( 468 ) 

DISEASES OF THE SUBSTANCES OF THE LtJKGS. 

Pneumonia .... Inflammation of the Lungs. 

Gangrsna PULMONUM . Gangrene of the Lungs, 

Hemoptysis .... Spitting of Blood. 

Phthisis Pulmoxalis . Pulmonary Consumption. 

PNEUMONIA— INFLAMMATION OF THE SUBSTANCE OF 
THE LUNGS. 

Synonyms. — Peripneumonia. PuJmonitis. Pneumonitis. 

Symptoms. — General. The disease sometimes sets in with rigors, 
followed by pyrexia ; at others the local symptoms are the first to 
show themselves. There is hi^h fever, with increased heat of surface, 
especially on the chest ; flushed face ; injection cf the eyes ; headache ; 
frequent, quick, and compressible pulse ; thirst, furred tongue ; ano- 
rexia; and great debility. The symptoms referable to the chest itself 
are a diffused, dull pain, deep-seated, rarely acute, unless the di.-ease 
involve the pleura ; a short, dry cough, at first with scanty mucous 
expectoration, but after the lapse of one or two days, with a rusty- 
coloured, xevy adhesive sputum ; the respiration is frequent and short, 
rising from 18 to 30 and upwards. 

In favourable cases, the disease may decline on the third or fourth 
day; more frequently it is protracted to ten days or a fortnight. In. 
unfavourable cases the symptoms increase on the third or fourth day ; 
the respiration becomes more and more frequent ; the sputa of a deeper 
hue, more viscid, and often streaked with blood ; the pulse increases 
in frequency and feebleness ; the tongue is dry and covered with a 
brown fur ; the skin hot and pungent to the touch ; the debility ex- 
treme; delirium and coma come on, with all the symptoms of the 
typhous state. In the last stage, the expectoration ceases to be viscid, 
and becomes a thin reddish-brown fluid ; the dyspnoea increases ; the 
pulse is small and fluttering ; the face pale ; the lips livid ; the skin 
covered with a clammy sweat ; there is an increasing rattle in the 
throat : and at length the patient dies exhausted, asphyxiated, or co- 
matose. Fcetid odour of the breath, and putrid sanious expectoration, 
announce the occurrence of gangrene. In favourable cases the symptoms 
gradually subside, and the sputa become less viscid and more abundant 
and of a purulent or mu co-purulent character. 

Local Symptoms, — Dulness over the inflamed lung, unless it lie far 
from the surface ; very fine crepitation ; bronchial breathing and bron- 
chophony, with increased respiration in the unaffected portions. Fine 
crepitation is the first indication of the congestive stage. It supersedes 
the vesicular murmur; continues to be heard for a day or so, and then 
gradually decreases till it is inaudible ; and it is now that the bronchial 
breathing and bronchophony are most marked. If the inflammation 
subsides, a little mucous crepitation begins to be heard, and soon in- 
creases in intensity and extent, until at last it becomes general, the 



PNEUMONIA. 469 

bronchial breathing and bronchophony meanwhile decreasing, and at 
last becoming extinct. The inflamed lung is again permeated by air, 
and the expectoration of viscid, rusty-colouied sputum is re-established. 
As the inflammation subsides, the moist sounds give place to the natural 
vesicular murmur, which, in returning, declares that the lung is being 
restored to its normal condition. Resonance on percussion is of couive 
established pari passu with the recovery of the lung. If, however, 
resolution do not take place, the dullness, tracheal breathing, and bron- 
chophony become very marked and persistent, and there is complete 
absence of vocal fremitis. But if the whole of one lung become con- 
solidated, tracheal breathing and bronchophony are absent, because no 
air can be drawn into it. If portions of the hepatized lung suppurate, 
and the abscess be discharged, the physical signs of a cavity, viz., pec- 
toriloquy, amphoric breathing, and gurgling (see Phthisis) will be 
present. The parts most commonly atfeeted are the lower lobes of one 
or both lungs ; and the local symptoms are most marked at the sides 
and back of the chest. 

Varieties and Complications. — Pneumonia is a frequent con- 
comitant of the latter stages of infectious fevers, of erysipelas, and 
pyaemia ; but is very liable to be overlooked. Great heat of the chest, 
unusual dyspnoea, and sudden aggravation of the symptoms, should 
lead ns to suspect this complication. The physical signs are the same 
as in idiopathic pneumonia. It often comes on during the deposition 
of miliary tubercle in the lung, constituting tubercular pneumonia. 
It attacks patients in the advanced stages of phthisis ; and is a frequent 
concomitant of bronchitis. Its most common combination is with 
pleurisy (pleuro-pneumonia). 

Morbid Anatomy. — In the first stage, sanguineous congestion. 
The lungs are gorged with blood, but still float in water. In the 
second, they are in a state of red hepatisation, and sink in water. Ex- 
amined with a pocket lens, the broken surface of the solidified lung has 
a fine granular appearance. The third stage is that of yellow hepa- 
tisation or diffused suppuration. The lung tissue is soft and rotten, 
and a depression made with the finger soon fills with purulent fluid. 

Causes. — Remote and predisposing . Sanguineous temperament, 
vigorous and plethoric habit, winter and spring seasons, a peculiar 
state of the atmosphere. Great debility and privation in the poor of 
large towns. — Exciting. The common causes of inflammation ; vicis- 
situdes of temperature, violent exercise of the body; congestion occur- 
ring from common causes, or in the course of various febrile diseases ; 
tubercular deposits ; heart disease. 

Diagnosis. — The adhesive, rusty-coloured sputa, the minute crepi- 
tation, the short, quick, silent breathing, and the physical signs just 
described, pneumonia. The history of the case distinguishes idiopathic 
pneumonia from typhus fever with chest complication. 

Prognosis. — Favourable. An early and copious mucous expectora- 
tion, the small crepitation changing to distinct mucous rale ; later in 



470 PNEUMONIA. 

the disease, an abundant mucopurulent expectoration, with return of 
resonance and respiratory murmur ; haemorrhage from the nose; warm, 
equable, and free diaphoresis ; diarrhoea ; inflammation on an external 
part; a sediment in the urine; diminished frequency of respiration 
(an extremely favourable symptom) ; the absence of complication; the 
disease of limited extent. — Unfavourable, Violent fever with delirium, 
or typhous symptoms ; no expectoration, or the expectorated matter 
tinged with blood of a dark colour or black ; sudden cessation of pain, 
followed by change of countenance, and a sinking or irregularity of the 
pulse ; increasing frequency of respiration ; a previously broken con- 
stitution ; the disease extending to the whole lung or to both lungs ; 
occurring in very young children, in the weak, or the aged. 

Treatment. — V> T ill vary with the stage of the disease. During the 
first or congestive stage, and in plethoric and vigorous subjects, blood 
may be taken from the arm, the bleeding to be followed by a brisk 
aperient, and by tartarized antimony, in half-grain doses, at intervals 
of one or two hours. The quantity may be increased to a grain, or 
even more, and it may be advantageously combined with calomel. Half 
a grain of tartar* emetic, with two of calomel, may be given every one 
or two hours, and mercurial ointment should meanwhile be rubbed 
into the arm-pits and groins until the gums are affected. This treat- 
ment, proportioned to the age, may also be employed in the pneumonia 
of infants. In less vigorous subjects, local depletion by leeches or 
cupping will suffice, and in weakly persons, counter-irritants, without 
abstraction of blood. As a general rule, bleeding is contra-indicated in 
the inhabitants of large towns, and still more in persons addicted to 
intemperance, who require a stimulant plan of treatment from the first. 
(A table-spoonful of the liq. ammonias acetatis every three or four hours. ) 

In the second stage, or that of hepatisation, blisters will be required, 
and calomel and opium should be given frequently, so as to affect the 
gums. If, however, there be high fever, tartar-emetic may still be 
continued in combination with the calomel ; but if typhous symptoms 
have already supervened, stimulants, such as ammonia and brandy, are 
called for. 

In the third stage, or that of suppuration or gangiene, stimulants 
such as ammonia, aether, and wine, must be freely given. Quinine 
and the mineral acids are the appiopsiate remedies for this condition. 

The foregoing remedies must be employed, with due regard to the 
severity of the local disease, as well as of the general symptoms. When 
bleeding is employed, its effects should be carefully watched. Debility, 
in the absence of marked typhous symptoms, does not contra- indicate 
it; and if the pulse rise under its use, it may be repeated. The diet 
must be fluid or pultaceous, and nourishing, but not stimulating. The 
patient's room should be of a moderate and equable temperature (about 
60°) ; the head should be raised as much as the patient's strength will 
allow, and the posture changed from time to time. 

In chronic pneumonia following the acute form, a course of mercury 
so as slightly to affect the svstem, counter-irritation, the iodide of 



HAEMOPTYSIS. 471 

potassium with decoction of bark, with change of air, regular exercise, 
and temperate diet, may be resorted to. The patient must be closely 
watched, and the chest examined from time to time. 



GANGR^XA PULMONUM—GANGRENE OF THE LUNGS. 

Symptoms. — Extreme prostration of strength ; a frequent, feeble 
pulse ; expectoration of dingy- green sputa, mixed with blood, and of a 
peculiarly offensive odour ; mucous rales and gurgling j marked 
typhous symptoms ; and death from exhaustion. 

Causes. — Pneumonia occurring in extremely feeble constitutions. 
Pulmonary apoplexy occasioned by pressure on the pulmonary veins. 

Diagnosis. — The pre-existence of inflammation, and the peculiar 
colour and offensive odour of the sputa. 

PPcOGNOSis. — Highly unfavourable, especially when the disease in- 
volves a large portion of the lungs. About an eighth of the cases 
terminate favourably. 

Treatment. — Strong stimulants and opium in full doses. . (R 
Ammon. carb. gr. x ; Tinct. Opii Tr\ xx to xxx.) The effect of the 
opium must be carefully watched. A liberal allowance of wine or 
spirits, and a nutritious diet. The chlorine gargle and mixture as re- 
commended in Scarlatina. Inhalations of tar-water. 



HAEMOPTYSIS— SPITTING OF BLOOD. 

Symptoms. — Genera!. Spitting of blood is often preceded by a sense 
of weight and oppression in the chest, or of uneasiness in some one spot, 
with slight febrile symptoms, a frequent, sharp, and compressible pulse, 
some difficulty in breathing, and a dry tickling cough. In some cases 
the mouth constantly fills with blood, without cough or irritation of 
the throat ; but in other cases the blood is brought up alone, or mixed 
with mucus, after long fits of coughing. The patient usually com- 
plains of a salt taste in the mouth. 

Local. — In some cases the chest affords the natural sound on per- 
cussion, and there is slight mucous rale ; in others there is dulness on 
percussion over a limited spot, surrounded by fine crepitation. In the 
first class, the haemorrhage is from the bronchial tubes (bronchial 
haemorrhage) ; in the second, blood is effused into the substance of the 
lungs (pulmonary apoplexy). In a third class of cases the spitting of 
blood occurs as a symptom of confirmed phthisis with the stethoscopic 
signs of a cavity. 

Causes. — Predisposing. A certain age — from the period of puberty 
to the forty-fifth year ; sanguineous temperament ; plethora ; narrow- 
conformation of the chest ; previous attacks of the same disease. — 
Exciting, Excessive heat ; violent exercise ; the lifting of heavy 



472 SPITTING OF BLOOD. 

weights ; inordinate exertion of the organs of respiration, as in public 
speaking, singing, &c. ; external violence. 

The most common cause of haemoptysis is the existence of tubercular 
deposit in the lungs, the haemoptysis in some cases preceding, in others 
following, the deposit. The next in point of frequency is vicarious 
haemoptysis, the consequence of amenorrhcea. Less frequent still is 
haemoptysis dependent on disease of the heart, or rupture of an aneurism. 
Least frequent of all is haemorrhage, caused by plastic bronchitis. 
Haemoptysis may occur in congestion of the lungs, however produced, as 
in pneumonia ; in the fit of congestive asthma ; and with haemorrhage 
from other organs, in purpura haemorrhagica, and purpura nautica. 

Diagnosis. — The blood is brought up by coughing, in small quan- 
tities, or mouthfuls at a time, of a florid red colour, and preceded by, or 
mixed with, a little frothy mucus. An abundant discharge of florid 
blood leads direct to the inference that the haemorrhage comes from the 
lungs, in consequence of the rupture of an artery communicating with 
the air- passages. 

From hcematemesis. — The blood thrown up in haematemesis is usually 
in much larger quantity, of a darker colour, more grumous, mixed with 
food, and usually unattended with cough. From haemorrhage from 
the nose, fauces, or gums. — By the negative result of a careful exami- 
nation of those parts, and the history of the case. 

Prognosis. — The prognosis is generally favourable, when the 
haemorrhage is not sudden and abundant ; when it takes the place of the 
menses in amenorrhcea ; or, in most other cases, in both sexes, its 
occurrence justifies a suspicion of the existence of tubercles : and in their 
ascertained absence of disease of the heart, is preceded or followed by 
the expectoration of solid exsudations from the bronchial tubes. 

Treatment. — Indications. I. To remove congestion. II. To keep 
the circulation quiet. III. To contract the relaxed vessels. 

I. The first indication is best fulfilled by bleeding from the arm. 
The circumstances which justify the adoption of this remedy are 
plethora, a full, frequent, and jerking pulse, great dyspnoea, a flushed 
countenance, and abundant haemorrhage. When the countenance and 
skin are pale, the pulse small and weak, and the respiration little 
affected, bleeding is not required. Bleeding is also contra-indicated in 
phthisical haemoptysis. Cupping may be substituted for general bleed- 
ing when the larger abstraction of blood is unnecessary. 

II. Low diet, perfect repose, fresh cool air, cold liquids, or ice held in 
the mouth, with gentle aperients, fulfil the second indication. The 
head of the patient should be raised, and he should avoid talking. If 
after bleeding there be still some febrile action, tartar-emetic, in doses 
of one-eighth to one-fourth of a grain, every three or four hours. 

III. After congestion or febrile symptoms have been removed, or in 
cases where there has been from the first no congestion or fever, the 
third indication will be fulfilled by remedies belonging to the class of 
astringents. (Form. 163, 175.) Digitalis, veratrum viride, and gallic 
acid are serviceable remedies. (Form. 173, 212, 213.) 



( 473 ) 



PHTHISIS PULMONALIS— PULMONARY" CONSUMPTION. 

Definition. — Tubercular deposit in the lungs, giving rise, sooner 
or later, to suppuration and hectic fever. 

Symptoms.— General, The disease usually begins with a short dry 
cough, on first rising in the morning, and so slight as to become habitual 
before it excites attention. It is sometimes accompanied by slight 
dyspnoea, increased on exertion, and the patient generally loses flesh, is 
soon fatigued, and easily thrown into a perspiration ; or he complains 
of unusual chilliness. Slight dyspepsia., diarrhoea, frontal headache, and 
a small, frequent, quick pulse, are also among the early symptoms ; and, 
on inquiry, we often learn that the patient formerly spat blood. 

These early symptoms are often disregarded, or misinterpreted ; so 
that the disease appears to begin suddenly with profuse haemorrhage 
from the lungs, with pneumonia, or with bronchitis. 

When the disease sets in in either of these ways, it sometimes destroys 
life in three or four weeks (Acute Phthisis). But in the great majority 
of cases it is chronic; and after the symptoms above described have 
continued for several weeks, months, or even years, in consequence of 
a cold, or some trivial exciting cause, the cough becomes more constant 
and troublesome, and is attended by expectoration, at first of a frothy 
mucus, afterwards of a more viscid and opaque sputum, often mixed 
with small round particles of tubercular matter, with pus, or with 
streaks of blood ; or well marked haemoptysis occurs. The dyspnoea 
increases, there are shooting pains in the chest, or cutaneous tenderness, 
and in many cases a peculiar hoarseness of the voice. 

As the disease advances, the cough and dyspnoea become more urgent, 
the expectoration more abundant, the emaciation and weakness more 
considerable, the pulse more frequent ; there are chills at noon or in the 
afternoon : the face flushes towards evening ; the palms of the hands 
and the soles of the feet are burning hot; in a word, hectic fever sets 
in, followed towards morning by profuse perspiration. The urine is 
high-coloured, and deposits a pink sediment. The tongue, from being 
white, is now preternaturally clean and red, and the appetite often 
improves. Profuse diarrhoea, sometimes tinged with blood, colliquative 
sweats, extreme emaciation, shedding of the hair, oedema of the legs, 
aphtha? in the mouth and throat, hectic fever in its mo<t marked form, 
and a very feeble, rapid, and often irregular pulse, usher in the fatal 
termination. In some cases the patient dies suffocated, having escaped 
many of the most distressing symptoms. In other instances delirium, 
and other indications of tubercular meningitis, precede the fatal event by 
some weeks. The appetite and spirits often remain good to the last; 
and the patient flatters himself with the hopes of speedy recovery, and 
is forming distant projects of interest or amusement, when death puts a 
period to his existence. 

Local Symptoms. — In the incipient stage, before suppuration sets in, 
dulness on percussion over the clavicles and in the supra and infra 
clavicular regions, but generally greater on the right than on the left 



474 PHTHISIS PULMONALIS. 

side. Similar dulness between the scapulae. The upper part of the 
chest, in some instances, is obviously contracted, the clavicles being very 
prominent, the supra-clavicular regions deeply hollowed, the anterior 
and upper part of the chest flattened, and the shoulders thrust forward. 
The respiratory movements are diminished. The stethoscopic indica- 
tions are a roughness in the respiratory murmur; a prolonged expiratory 
sound ; bronchial respiration and bronchophony, heard more distinctly 
on one side, and most to be depended on as a sign of incipient phthisis 
when heard towards the point of the shoulder ; mucous crepitation ; 
increased resonance of the voice ; in some cases, extremely indistinct 
respiiatory murmur ; puerile respiration in the sound parts of the lungs. 
The heart sounds are peculiarly distinct over the whole chest. 

In confirmed phthisis, one or more of the following physical signs are 
superadded to the foregoing : — coarse crepitation ; more decided bubbling 
sound or click, which is most distinctly heard when the patient coughs 
or takes a full inspiration ; cavernous rhonchus ; cavernous respiration ; 
pectoriloquy; amphoric resonance ; metallic tinkling ; distinct gurgling 
when the patient coughs ; and, in rare cases, equally distinct sound of 
flu'.d in motion on succussion ; the cracked-metal sound, on sharp per- 
cussion. The situation in which these sounds occur, and the limited 
space which they occupy, will generally serve to distinguish phthisis 
from other conditions of lung productive of the same or similar sounds. 

The sputa are at first frothy, as in bronchitis ; then mucous, then 
flocculent, resembling "irregular balls of flock or wool, of a yellow or 
greenish colour, sinking and breaking down in water;" and lastly 
purulent, often sinking in water, and sometimes containing particles of 
clotted matter, like softened cheese. The sputa are often streaked or 
spotted with blood; sometimes they are discharged in the masses, 
designated <; nummular sputa," which the patient compares to 
" oysters." In rare instances, distinct portions of pulmonary tissue are 
spit up, having under the microscope the appearance depicted in Fig. 48, 
p. 199, and still less frequently cretaceous or earthy matter. The 
frothy and mucous expectoration attend the early stages of phthisis, the 
flocculent and purulent the more advanced. Haemoptysis may occur 
both in the early and in the advanced stages. 

Morbid Anatomy. — In the lungs, tubercular matter, as miliary 
tubercles or granulations scattered through the lungs ; or as opaque 
yellowish-white or cheesy masses infiltrated into their texture. Cavities 
of various size and shape, sometimes found in every part of the lung, 
but generally confined to the upper lobes, larger and more numerous on 
the right than on the left side. The liver enlarged, and changed in 
appearance and consistence (the fatty or nutmeg liver). Tubercular 
deposits in various organs of the body. Tubercular ulcerations of the 
larynx, trachea, and intestines (see partial enteritis). Of Louis' cases, 
ulceration of the larynx occurred in i, of the trachea in J, of the intes- 
tines in §. Tubercle is originally a cellular formation, the constituent 
cells being imperfectly developed ; many are little more than mere 
nuclei, and the largest are rather smaller than pus corpuscles. Virchow 



PULMONARY CONSUMPTION. 



475 



shows that the tubercle corpuscles, like those of pus, are developed 
from the corpuscles of the connective tissue. As long as the cells remain 
unaltered, the tubercle retains its grey semi-transparent appearance, 
but sconer or later thev become disintegrated into fatty granular debris, 




and the tubercle is changed into a yellowish cheesy mass. Fig. QQ shows 
the whole succession of transitions from (a) the connective tissue cor- 
puscles, up to the production by the division and multiplication of their 
nuclei, of the tubercle corpuscles (6). These in the centre of the tuber- 
cular mass are undergoing disintegration into cheesy matter (Virchow). 

Complications. — Bronchitis, pneumonia, and pleurisy, followed by 
adhesions or by pneumothorax. Ulceration of the larynx and trachea. 
Disease of the liver ; peritonitis ; oedema of the ankles, anasarca, ascites ; 
ulceration of the intestines ; fistula in ano ; mania. 

Duration. — Average about two years. In acute cases, from a few 
months to one or two years. In very acute cases, three weeks or a 
month. In chronic cases, death often takes place after the lapse of years, 
and after repeated attacks of haemoptysis. 

Causes. — Predisposing. Hereditary predisposition (in about one- 
fourth of the cases) ; the scrofulous diathesis ; adult age. The male 
sex. A particular formation of the body, marked by a long neck, pro- 
minent shoulders, narrow or deformed chest, long slender ringers, with 
filbert nails, regular, white teeth, and gums with a deep red margin ; 
thin upper lip; a fine clear skin, delicate complexion, fine hair; 
debility. Dr. Buchanan's recent laborious researches have elicited the 
important and comprehensive fact, that " wetness of the soil is a cause 
of phthisis to the population living upon it." — Exciting. Foregone 
attacks of pneumonia, catarrh, asthma, scrofula, syphilis, variola, 
rubeola. The dust to which certain artificers are exposed, as needle- 
pointers, stone-cutters, pearl-button makers, millers, &c. Irritating 
fumes. 

Mortality. — The disease is fatal (but often after several attacks) 
in the vast majority of cases. It destroys about a ninth part of the 



476 PHTHISIS PULMOXALIS. 

English population, and about a fifth of those who attain the adult age. 
In the metropolis it causes about a seventh of the deaths at all ages, 
and about a fourth of those of adults. The old bills of mortality show 
a like proportion of deaths among adults. 

Diagnosis. — The symptoms and physical signs taken together render 
the diagnosis of confirmed phthisis easy, but it is often difficult in the 
incipient stage, in cases of extensive miliary deposit without suppura- 
tion, and when complicated with other chest affections. The following 
observations may facilitate the diagnosis. The first onset of phthisis 
is marked by very slight and very variable symptoms, such as debility ; 
debility and slight emaciation ; perspiration on slight exertion ; 
dyspepsia ; diarrhoea ; slight haemoptysis ; hacking cough, with scanty 
mucous expectoration in the morning : palpitation. A few well-directed 
inquiries will generally bring to light some additional symptom. In all 
obscure cases, the character of the pulse specially deserves attention, as 
it affords indications quite as valuable as those obtained by an exami- 
nation of the chest. When the disease is advanced it is most liable to be 
confounded with bronchorrhcea. with dilated bronchi (see Bronchitis), 
and with suppuration of the lung after pneumonia. From the latter it 
will be distinguished by the previous history, and by the character of 
the sputum. 

The Pulse in some cases excites suspicion, in others confirms it, by 
1, increased frequency ; 2, diminished volume ; 3, increased quickness 
or sharpness ; or 4, by all three combined. 

1. In five cases out of six the number of the pulse exceeds the highest 
number (92) observed in apparently healthy males of the same mean 
age ; while in the great majority of instances it exceeds the average. 
Sometimes this increased frequency of the pulse accompanies the first 
feelings of indisposition, and continues throughout the disease. I have 
known it as high as 140, where debility was the only marked symptom. 
On the other hand, cases do occur, though very rarely, in which the 
pulse is even less frequent than the average in health. [Jan. 1853. — 
P.D., aged 34, a policeman. When 24 years old he had an attack of 
pneumonia (?), which confined him to bed for six weeks. During the 
attack he spat half a pint of blood mixed with yellow sputa, for several 
days in succession. W 7 hen 26 years of age, he had an attack of pleurisy, 
for which he was bled. During the two years that he has been in the 
police force he has always had a cough, and when aged 33, again spat 
a little blood. Spits large quantities of yellow sputa, but no blood at 
present. There is dulness on percussion above and below both cla- 
vicles, with cavernous respiration, increased expiratory murmur, and 
pectoriloquy above the right clavicle ; increased expiratory murmur 
and slight crepitus about the left clavicle. Pulse, standing, 64. He 
is still able to follow his employment. August, 1853. — External ap- 
pearance and symptoms little changed, but the pulse now above 100, 
in the same posture. June, 1858. — Still in delicate health, but follow- 
ing his employment as a beadle.] — 2. The diminished volume of the 
pulse is an almost constant character, and is present even in such excep- 



PULMONARY CONSUMPTION. 477 

tional cases as the above. — 3. The quickness of the p ilse — that is 
to say, the promptitude with which each separate puke rises beneath 
the finger — is also even more constant than the increased frequency, 
and may exist with a pulse of 70. The pulse of health is exactly the 
reverse of this, rising slowly, and, as it were, deliberately, beneath the 
finger ; so also is the infrequent pulse of mere debility. To quickness 
is superadded smallness of pulse in phthisis, whilst the pulse in health 
is of moderate fulness. — 4. The combination of the three characters of 
pulse — the frequency, the smallness, and the quickness — should always 
lead to an examination of the chest; but the small quick pulse alone is 
sufficient ground of suspicion. These observations apply only to men, 
as the characters here pointed out form a striking contrast to those of 
the male pulse both in health and disease ; while, on the contrary, the 
pulse of the female, even in health, possesses these three characters in 
a marked degree, and assumes them in most functional and in many 
organic diseases. A small, quick, and frequent pulse is, therefore, less 
indicative of consumption in women than in men. The slight effect 
produced by a change from the erect to the sitting posture will also 
assist the diagnosis in the male, by distinguishing the debility of 
phthisis from simple debility due to other causes. Whenever, then, a 
man presents himself for advice, complaining of debility, or of other 
obscure symptoms of phthisis, or even of symptoms proper to func- 
tional diseases of other organs, and is at the same time obviously free 
from acute disease, the pulse should be examined, and if, after allowing 
the patient's agitation to subside, it is either very small and frequent, 
or very small and quick, or if it combine the characters of increased 
frequency, smallness, and quickness, the chest should be examined, 
and in by far the majority of cases the physical signs will justify the 
suspicion raised by the pulse. In examining persons offering them- 
selves for assurance, the state of the pulse should be particularly 
attended to. It may be well to observe that, in consequence of the 
quickness of the pulse (the promptitude with which each beat is per- 
formed usually seems much less frequent than it is), it should, there- 
fore, be always counted by the watch. (G.) 

Headache. — A dull, persistent pain in the forehead and over the 
eyes has often led me to examine the chest, and in most instances with 
the result of confirming my suspicions. (G.) 

Palpitation. — This too may be the very first symptom to engage the 
patient's attention. (G.) 

Prognosis. — Unfavourable, as to the ultimate event, but guarded 
as to that of an existing attack, for the patient may survive three, 
four, or more severe attacks. An existing attack is likely to terminate 
fatally when there is a high degree of hectic fever ; great frequency of 
pulse and respiration ; great emaciation and debility ; a morbidly- 
clean or fiery-red tongue ; fixed pain in the chest ; colliquative sweats 
or diarrhoea ; profuse purulent expectoration ; oedema of the legs ; 
aphthse ; and stethoscopic indications of extensive and advanced disease, 
or of the supervention of pneumonia or pleuritis. 



478 TREATMENT OF PULMONARY CONSUMPTION. 

There is a better prospect of a favourable result to an existing attack 
when the disease is limited in extent, and not traceable to hereditary 
predisposition ; when there is little loss of strength and flesh ; when the 
pulse and respiration are little increased in frequency ; when there are 
no night -sweats, no diarrhoea, and no complications. When the disease 
is very limited, ultimate recoveiy is a possible, though very rare, 
event; and every experienced physician has met with a few cases in 
which men who had every symptom of consumption in early manhood 
have attained advanced age. In females, the first attack is more gene- 
rally fatal than in males. 

Pneumonia in the young or middle-aged adult, not yielding to treat- 
ment, and accompanied by rapid loss of flesh and strength, is probably 
due to tubercular deposit. Bronchitis also, occurring at the same 
periods of life, and characterised by similar features, is probably due to 
miliary deposits occupying the whole, or the greater part of, both lungs. 

Treatment. — I. Of incipient phthisis. II. Of confirmed phthisis. 

I. In incipient phthisis, the indications are — (a) .To promote the 
absorption of the tubercular matter; (6) To prevent or subdue local 
inflammation ; (c) To improve the general health. 

{a. j With a view to piomote the absorption of tubercle, iodide of 
potassium or of iron may be prescribed. Iodine may also be inhaled 
with the steam of warm water. 

(b.) Local inflammation may be prevented by guarding against cold 
and all causes that excite the circulation. Warm clothing ; the avoid- 
ance of wet and cold ; and due attention to the secretions, will fulfil the 
first part of this indication. Inflammation may be subdued by leeches 
applied occasionally over the site of the painful spot ; by counter-irri- 
tants to the upper parts of the chest, of which croton liniment and 
tartar-emetic ointment are the best. 

(c.) The general health may be improved by proper exercise, whole- 
some diet, regular habits, pure air, change of air, especially to the sea- 
side, sea voyages, cold sponging followed by friction every morning. 
Chalybeate tonics. Iodide of iion. Cod-liver oil if there be emaciation. 

II. In confirmed phthisis — that is to say, where suppuration has 
already taken place — the indications are — [a) To facilitate expectora- 
tion ; (6) To subdue local inflammation ; (c) To mitigate distressing 
symptoms ; (d) To support the patient's strength. 

(a.) The first indication is fulfilled by emetics. When the patient's 
strength is little impaired, and the expectoration is abundant, they may 
be given with the best effect. A scruple of sulphate of zinc should be 
taken on first rising in the morning, every day, or on alternate days, 
or once or twice in the week, according to the strength of the patient, 
and be followed up by a moderate quantity of warm water or warm 
camomile tea. 

I am inclined to restrict the use of emetics to those cases in which 
there is abundant expectoration. In incipient phthisis, attended with a 
dry cough, or scanty expectoration, emetics are as useless as they might 
a priori be expected to be. (G.) 



PHTHISIS PULMONAIJ& 479 

(6.) Local inflammation must be combated as before indicated. 

(c.) The most distressing symptoms are night-sweats, coughs, febrile 
flushes, palpitations, sickness, diarrhoea, and haemoptysis. The palpi- 
tation may be relieved by digitalis, in doses of from x to xx drops of 
the tincture ; the cough, by small doses of opium, compound squill 
pill, in combination with the extract of conium, or by small and re- 
peated doses of the more powerful sedatives. Of these the best is 
extract of stramonium, in the dose of the sixth of a grain made into 
the form of lozenge with extract of liquorice, and sucked frequently in 
the course of the day and night when the cough is most urgent. A 
linctus containing chloroform and hydrocyanic acid may also be given 
with advantage. The febrile flushes are relieved by tepid sponging and 
cooling drinks. The night-sweats often subside under the use of the 
dilute sulphuric acid, in the dose of twenty drops. This may be com- 
bined, when there is much restlessness, with a quarter of a grain of 
morphia. The distressing sickness which sometimes accompanies 
phthisis is relieved by the use of hydrocyanic acid and bismuth (Form. 
85), with a bland farinaceous diet. Diarrhoea commonly subsides by 
strict regulation of the diet, and the prohibition of every form of solid 
food. If it be caused by ulceration, the treatment recommended under 
partial enteritis must be adopted. In haemoptysis, the dilute mineral 
acids (Form. 163), or, if these fail, Form. 173, 175, 213. 

(d.) The patient's strength is best supported by nourishing and 
unstimulating diet. In the last stage of the disease, however, stimu- 
lants, such as wine and ammonia, may be given with advantage. 

Remedies. — Xeat's-foot oil. Glycerine. Cod-liver, or neat's-foot 
oil rubbed into the skin of the chest, when the stomach rejects them. 
The inhalation of oxygen, iodine, chlorine, hydrogen, hydro -carbon, and 
the vapours of tar. Alcohol. Naphtha, The Iceland or Irish moss. 

In incipient phthisis, a sea voyage, or a change of air and scene, or a 
change from a low damp spot to a dry bracing air, prove as useful as 
to other persons whose health is impaired from whatever cause. This 
is probably the extent to which change of climate is beneficial in the 
early stage of phthisis. As, however, it has been shown that, in the 
East Indies, there is among our troops, as well as among the natives, a 
comparative immunity from consumption, a residence in that climate 
may be reasonably recommended, both to persons labouring under the 
incipient disease, and to families deeply tainted with scrofula. The 
places now usually recommended have not this probability in their 
favour, and the evidence in support of the change is on a level with 
that in favour of tar-water, naphtha, frictions to the spine, or dry- 
cupping to the chest. The fact is, that everything that has ever been 
recommended, however trivial, has seemed to effect a cure of consump- 
tion, simply because patients suffering from it do continually recover 
from existing attacks, and in rare instances regain perfect health, though 
pent up in towns, breathing the ioul air of crowded workshops, living 
in unhealthy habitations, and surrounded by every unwholesome influ- 
ence ; exposed, in a word, to the continued action of the predisposing 



480 PULMONARY CONSUMPTION. 

and exciting causes of the disease ; while, on the other hand, many 
cases, stated to be phthisis, are merely sympathetic functional disorders 
of the lungs, or real diseases of the lungs of a non-tubercular origin. 
To recommend a change of climate in advanced stages of consumption 
is both unwise and cruel. But in incipient cases, a change may be 
fairly recommended, if it do not entail great inconvenience ; for it is 
always a choice of evils, which ought to be fairly stated. The benefit 
is not sufficient to counterbalance great inconvenience or a large pecu- 
niary sacrifice. (G.) 

Prophylaxis. — Persons who have an hereditary predisposition to 
phthisis, and those who have habitually delicate health, require un- 
usually careful management. Duiing childhood, nourishing and whole- 
some food, proper exercise, warm clothing, pure air within doors, both in 
day and sleeping -rooms, moderate application of the mind, and careful 
attention to the state of the bowels, are necessary. During youth and 
manhood such exercises as tend to expand the chest, especially fencing 
and military drill for men, and archery for women ; exercise in the 
open air, especially horse exercise ; the cold sponge with bath every 
morning, followed by friction ; the moderate employment of the voice 
in singing or reading aloud; and careful avoidance of all excesses, 
bodily or mental, should be insisted on. All unwholesome employ- 
ments and all sedentary occupations should be avoided. Residence in 
a dry warm climate, such as Undercliff, Torquay, Hastings, Cork, 
Madeira, the East and "West Indies, the south of France, or Italy, 
Algiers, Cape of Good Hope, or Australia. Astringent chalybeate tonics. 



DISEASES OF THE PLEURA. 

Pleuritis . . . Inflammation of the pleura. 
Hydrothorax . . Water in the chest. 
Pneumothorax . . Air in the chest. 

PLEURITIS— INFLAMMATION OF THE PLEUEA. 
Varieties. — 1. Acute. 2. Chronic. 

1. ACUTE PLEURISY. 

Symptoms. — General. After rigors, and the symptoms of inflam- 
matory fever, a sense of weight in the chest, which in a few hours 
becomes acute pain, referred to the side, about the level of the nipple, 
thence shooting to the sternum, clavicle, and arm-pit, and in rare cases 
over the whole of the affected side. There is a short dry cough, 
unless the disease be complicated with bronchitis, pneumonia, or 
phthisis: in which case, the patient expectorates sputa characteristic 
of those diseases. The countenance is expressive of anxiety ; the 
breathing is short and catching, and performed chiefly by the abdo- 
men ; the pain is increased by deep inspiration, by the act of coughing, 
or by lying on the affected side. The pulse is frequent, hard, and con- 
tracted, vibrating under the finger like the tense strino- of a musical in- 



ACUTE PLEURISY — CHRONIC PLEURISY. 481 

strument. The tongue is covered with a white fur ; the urine is scanty 
and high-coloured ; the skin hot. and the cheeks Hushed. 

Sometimes severe and extensive pleurisy occurs without these marked 
characters. The pain is more diffuse, less severe, or produced only by 
pressure between the ribs of the affected side ; and in some instances it 
is altogether absent. In most cases the acute pain, as well as the 
fever, subside on the third or fourth day, and the cough and dyspnoea 
abate, though the pleura is still inflamed. 

Local. — When the disease is recent, the effusion scanty, and the 
surfaces of the pleuras not adherent, there are feeble respiratory 
murmur from diminished motion of the chest, slight dulness, friction- 
sounds, cessation of vocal fremitus, and aegophony. If adhesion takes 
place, the friction- sounds cease ; and if effusion occur to a considerable 
extent, the physical sounds are those stated under Empyema. 

Terminations. — In resolution ; in adhesion ; in effusion followed 
by collapse of the lung; in the chronic form. 

Morbid Anatomy. — Injection of the subserous cellular membrane 
with dryness of the surface of the pleura ; effusion of coagulable lymph , 
or of pus mixed with flakes of lymph; and recent adhesions. 

Causes. — Predisposing. Rheumatic diathesis. — Exciting. Cold; 
external injuries, fractures of the ribs, &c. ; febrile states of system : 
inflammation of adjoining textures ; tubercles in the lung ; fever. 

Diagnosis. — From pleurodyne, by the severe constitutional symp- 
toms and characteristic local signs. From other diseases of the chest, 
by the physical signs. 

Prognosis. — Favourable, A recent attack promptly treated ; ab- 
sence of complications ; if the disease be not recent, the absence of hectic, 
and of great debility. — Unfavourable. Rapid and extensive effusion : 
implication of both sides of the chest ; the coexistence of organic disease ; 
hectic fever and great debility ; dropsy. 

Treatment. — In the robust a full bleediDg from the arm to the 
approach of syncope, followed immediately by full doses (from a quarter 
to half a grain, or even more) of tartarated antimony, every one, two, 
or three hours, brisk aperients, and a strict antiphlogistic diet. For 
slighter degrees of inflammation, cupping and leeches and blisters. The 
antimony may be usefully combined with calomel. The one keeps up 
the effect of the bleeding, till the other, by slightly affecting the system, 
puts a stop to the inflammatory action. 

2. chronic pleurisy. 

Symptoms. — Chronic pleurisy is usually a consequence of the acute 
form, but it sometimes begins as a subacute disease. In either case, 
hectic fever, a permanently accelerated pulse, emaciation, dyspnoea 
increased by exertion, and inability to lie on the healthy side, are the 
chief symptoms. These are apt to alternate with acute symptoms, such 
as severe pain, and increased hardness of the pulse. 

2 I 



482 . HYDROTHORAX. 

Anatomical Characters. — Effusion of fluid into the sac and co- 
agulable lymph upon the surfaces of the pleura ; old and recent ad- 
hesions. 

Treatment. — The first object is to promote the absorption of the 
effused matter. For this purpose, mercury (Form. 329) may be given 
until constitutional effects are produced, or if there be much debility 
the continued use of iodide of potassium, the infriction of iodine unguents, 
the repeated application of blisters. 

The general strength must be supported by the use of tonics ; and in 
cases of great debility, by stimulants and a nourishing diet. 

These measures will often cause the absorption of the effused fluid; 
but when there is much, and especially when it is chiefly or wholly 
pus, absorption rarely occurs, and the disease now takes the name of 
empyema. 



HYDROTHORAX— EMPYEMA. 

The former term signifies a collection of serum, the latter a collection 
of pus, in one or both cavities of the pleura. The physical symptoms 
are the same whether the fluid be pus or serum. At first it is impos- 
sible to say positively which of these two fluids is effused. The general 
symptoms are those of chronic pleurisy. When the effusion into one 
side of the chest is considerable there is dyspnoea, increased upon 
exertion ; and upon lying down. There is a distressing weight and op- 
pression at the chest; the face is pale or dusky, and expressive of 
anxiety. Palpitation is often a distressing symptom. There is a dry 
distressing cough, with expectoration generally tinged with blood. In 
describing his sensations, the patient frequently speaks of breathing 
through water. There is inability to lie on the sound side ; but when 
the disease exists in both cavities of the chest, the patient cannot lie 
down at all. 

When the effusion is purulent, ulceration is apt to occur in some of 
the surrounding textures, and an opening is formed into the lungs, 
thiough the walls of the chest, or through the diaphragm. The bones 
may also become carious. When the matter points externally, fluctua- 
tion is perceived in the part, and the integument becomes tense during 
expiration. When an opening takes place into the lungs, a large 
quantity of offensive matter is discharged during a fit of coughing, and 
this is followed by great relief to the breathing. When the opening 
forms externally, the discharge of matter is increased by coughing. 

The local signs are as follows : — Enlargement of the diseased side, 
proportioned to the extent of the effusion ; the ribs raised as in full 
inspiration; the intercostal spaces bulged, level with the ribs, and some- 
times perceptibly fluctuant. When the effusion is great, universal 
dulness on percussion in all postures, with absence of respiratory 
murmur; displacement of the heart to the right. When moderate, 
the dulness on percussion, and the respiratory and vocal sounds shift 



EMPYEMA. 483 

with the position of the body. Puerile respiration on the sound side, 
proportioned to the degree of compression on the lung of the diseased 
side. When the effusion is slight, segophony, generally most distinctly 
heard about the angle of the scapula. 

Treatment. — Having failed to produce absorption by the general 
and local treatment above mentioned, it will be necessary, as soon as 
the breathing is seriously affected, to remove the fluid, if we have 
reason to believe that it is serum, the operation should be delayed as 
long as is consistent with the safety of the patient ; but it should not 
be delayed so long that the lung becomes completely collapsed and 
incapable of re-expansion. If we have positive indications that the fluid 
is pus, we evacuate it at once. If the matter should point in any part 
of the chest, a large orifice should be made there, by means of a scalpel, 
for its free evacuation ; but if not, we select a spot midway between the 
spine and sternum, and if the effusion be not very great, a small incision 
being previously made through the skin with a scalpel, a full-sized 
trocar should be pushed horizontally inwards, perpendicular to the 
median plane, above the upper margin of the fifth rib on the left side, 
of the fourth on the right side. When the effusion is great, we may 
operate above the fifth right rib, and the sixth left rib. Before the 
introduction of the trocar, the skin should be drawn upwards, so that 
afterwards the external and internal opening may not coincide. To 
prevent the introduction of air during the operation, the canula should 
be attached to an indiarubber tube, rilled with water, and its free ex- 
tremity suspended in water. By means of a stop-cock the fluid should 
be allowed to flow very slowly from the chest ; and meantime we should 
ascertain, by the stethoscope, whether the lungs are proportionately 
expanding. As long as they continue to do so, we may allow the fluid 
to slowly flow ; but as soon as they cease to expand the flow should be 
stopped, or air will be admitted into the pleural sac. The more slowly 
the fluid is removed, the less chance there will be, both of the admission 
of air and of renewed effusion. Simultaneously with the withdrawal 
of the canula, and while the patient is holding the breath, or expiring, 
the integument should be slipped over the orifice in the chest wall, and 
retained there by means of adhesive plaster. If we discover the fluid to 
be pus, the canula may be withdrawn, a free incision made, and a 
drainage-tube inserted. 

Pressure by means of a bandage may be advantageously employed 
both during and after the operation. 

In many cases the removal of the fluid, whether brought about by 
internal remedies or by operation, cannot take place without more or 
less affecting the shape of the chest ; the lung may be either perma- 
nently condensed by the pressure, or bound down by firm adhesions. 
As the fluid, then, is absorbed, the ribs fall in, and the chest shrinks. 
The shoulder falls, and remains more fixed than that of the sound side, 
the scapula approaches the spine and is more prominent, and the spine 
itself is often concave towards the same side. The lung of the sound 
side, expanding beyond its usual limits, displaces the heart. These 



484 PNEUMOTHORAX. 

changes are accompanied by appropriate physical signs of condensed 
lung, namely, dulness on percussion, impaired respiratory murmur, 
bronchophony, and rocal fremitus. When the effusion is partial and 
confined by adhesions, the contraction is also partial, and the physical 
signs are more limited in extent. Pleurisy may occur in young people, 
and lead to great defoimity, without much impeding the breathing; 
but when it attacks the adult, it generally leaves behind it some 
dyspnoea, with a strong tendency to recurrence. 



PNEUMOTHORAX— AIR IN THE CHEST. 

Air may find its way into the cavity of the pleura in two ways : 
1. By an opening in either the pulmonary or parietal pleura. 2. By 
secretion. The first is the more common cause. 

Symptoms. — These vary with the circumstances under which the 
opening takes place, and the previous condition of the pleura. When 
a superficial ulcer of the lung opens into a previously healthy pleural 
sac, the entrance of air gives rise to dyspnoea, acute pain, dry cough, 
spasms of the intercostal muscles, a rrequent, feeble, and sometimes 
irregular pulse. These symptoms, which are more or less sudden, 
according to the size of the opening, are soon followed by those of in- 
flammation of the pleura. When inflammation pre-exists, the presence 
of air not only tends to increase it, but converts the otherwise inodorous 
pus into a fetid fluid. 

Physical Signs. — Unusually clear tympanitic sound on percussion, 
with great indistinctness or total absence of respiratory murmur on the 
affected side : the breathing has an amphoric resonance, and the voice 
and cough are attended by a metallic ringing echo, like that produced 
by speaking under a stone arch. There is increased distinctness of the 
respiratory murmur on the sound side. When there is liquid as well 
as air in the pleural sac, the physical signs are, dulness on percussion as 
high as the level of the fluid, which shifts with change of posture ; 
metallic tinkling, and splashing on succussion. 

Prognosis. — Unfavourable, but life is often prolonged for months. 

Treatment. — This depends upon the stage of the disease, and the 
state of the patient. The sudden rapture of the lung is generally fol- 
lowed by symptoms of collapse and irritation, requiring stimulants and 
opium; when inflammatory symptoms come on, antiphlogistic measures 
are required. It may be necessary to resort to local depletion by cupping 
or leeches, and to counter-irritation. Tartar-emetic may be given in 
nauseating doses, and the bowels should be kept free by gentle aperients. 
When extreme dyspnoea is present, an opening must be made with a fine 
trocar to give exit to the air, and this should be done at a part of the 
chest below the level of any liquid it may contain. The operation may 
be repeated if necessary. 



( 485 ) 



CHAPTEE IV. 

DISEASES OF THE DIGESTIVE CANAL AND ABDOMINAL 

VISCERA. 

1. Diseases of the Mouth, Fauces, and Gullet. 

2. Diseases of the Stomach. 

3. Diseases of the Intestines. 

4. Diseases of the Stomach and Intestines. 

5. Diseases of the Peritoneum. 

6. Diseases of the Liver, Pancreas, and Spleen. 

DISEASES OF THE MOUTH, FAUCES, AND GULLET. 

Stomatitis Inflammation of the Mouth. 

Gingivitis Inflammation of the Gums. 

Glossitis Inflammation of the Tongue. 

Tonsillitis Inflammation of the Tonsils. 

Parotitis Inflammation of the Parotid Gland. 

Cynanche Thyroidea . . Bronchocele. 

STOMATITIS— INFLAMMATION OF THE MOUTH. 

Varieties. — 1. Stomatitis erythematosa ; 2. S. follicularis ; 3. S. 
fungosa (aphthse) ; 4. S. mercurialis ; 5. S. gangrenosa. 

1. stomatitis erythematosa seu vesigularis. 

Symptoms. — This is a disease of early infancy, characterised by 
redness and heat, and sometimes by dryness, of the mouth and tongue, 
and the eruption of groups of minute vesicles on the top and around 
the edges of the tongue. It often coexists with inflammation of the 
stomach and bowels. In infants from the seventh to the ninth month 
fever is often superadded. The inflammation may extend to the whole 
mouth, and even to the lips, which swell, excoriate, and sometimes 
become the seat of herpes. The chronic form is often attended by 
profuse salivation. 

Treatment. — If the mouth and tongue be dry, lint or fine sponge 
moistened with thin barley-water should be frequently passed over 
them. The diet should be of milk combined with a little fluid mag- 



486 STOMATITIS FUNGOSA. 

nesia, given, if the bowels be irritable, in small quantities at short 
intervals. 

2. STOMATITIS FOLLICULAPJS. 

Symptoms. — Large, roundish, elevated, white, thick-walled, distinct 
vesicles, on the inner surfaces of the lips and cheeks, the sides of the 
tongue and the gums. The vesicles usually present a depressed centre 
and a minute point, the sealed orifice of the follicle. They soon break, 
and discharge a little glairy fluid. A minute superficial ulcer, bounded 
by a red margin and apt to spread a short distance, follows. 

* The disease attacks children about the time of the first teething. 
Old people are also liable to it. 

Cause. — Inflammation of the mucous follicles, and simple racemose 
glands, sympathetic with some disorder of the alimentary canal. 

Treatment. — For infants 5j doses of solution of bicarbonate of 
magnesia, and solution of nitrate of silver locally applied. In adults 
attention to the disordered function of the alimentary canal. 

3. STOMATITIS FUNGOSA — THRUSH. 

Under the specific name fungosa are included all the aphthous affec- 
tions known to be due to the presence of fungi. 

Definition. — Mouldiness of the mucous membrane of the mouth. 

Synonyms. — S. membranosa. Aphthae. Muguet. Millett. 

Symptoms. — White, opaque, conical, irregularly-rounded or ring- 
like, elevated patches, appearing alone or simultaneously on the inner 
surface of the lips and cheeks, on the gums, palate, tonsils, both sur- 
faces, and especially the sides of, the tongue. Sometimes the disease 
extends down the oesophagus into the stomach, and along the respiratory 
passages into the bronchi. In aggravated cases the patches become 
confluent, and form a loose, ragged membrane of a dirty-white or 
greyish colour, extending over a considerable portion of the tongue or 
cheek. They soften down and become ragged on their surfaces, and 
after a variable time (from ten hours to several days) separate, and 
leave either a smooth, red, unbroken surface, or a superficial excori- 
ation. The abraded surface may now become covered with healthy 
epithelium, or the diseased condition maybe reproduced. This affection 
is a fiequent accompaniment of gastro-intestinal irritation in weakly 
infants. There is increased difficulty of sucking and swallowing. If 
the disease extend into the alimentary canal, it will be liable to produce 
vomiting and diarrhoea, with mucous stools. Coughing and mucous 
expectoration, mixed with grey aphthous threads, mark its extension 
into the air-passages. When the child is in a low state of health, the 
aphthae sometimes produce unhealthy sores, the surrounding parts be- 
come swollen, soft, and livid, there is profuse salivation ; and the child, 
refusing food, becomes pale and cold, and at last dies of inanition. 



THRUSH. 



487 




. Causes. — Predisposing. A tender epithelium as m infants, and after 
desquamation, resulting from local or general disease. The disease 
affects persons of all ages. — Exciting. The development of a parasitic 
fungus (Oidium albicans) in the epithelial covering of the mucous 
membrane. The plant consists of minute tubular jointed filaments, and 
of bright spherical or oval spores developed at the joints and extremities 
of the filaments. 

The spores and Fig, 

the joints of the 
thread-like stems, 
contain one or two 
bright rounded 
granules (Fig. 
67). The fila- 
ments grow in be- 
tween the epi- 
thelial cells in 
every direction, 
and form a net- 
work, into the 
meshes of which 
the spores are 

poured, disturbing and loosening the epithelium, which becomes swollen, 
opaque, and friable. The disease rarely extends below the cellular 
layer; but as the deepest growing portion of this layer is frequently 
invaded, the disease is not thrown off when the superficial parts are 
separated. Sometimes the disease extends to the corium itself, pro- 
ducing unhealthy ulceration. The racemose glands are a favourite 
seat of the fungus, their little open-mouthed ducts allowing of its 
ready introduction to the softer cells within them. 

Coxt agiox. — Since the disease is dependent on the growth of a 
fungus, it follows that its presence, and a favourable condition of the 
mucous membrane, will always result in its development. The fungus 
is very probably derived, in the first instance, from some mouldy article 
of diet. When once established, it may spread from one child to 
another throughout a foundling hospital. The disease maybe conveyed 
from the child's mouth to the nurse's nipples, and from the latter to 
the mouths of other children ; and by the common use of domestic 
articles, baths, &c. 

Treatment. — Gastric irritation and diarrhoea, which frequently 
attend this disease, must be treated on general principles. The mouth 
should be frequently gargled (Form. 69). Solution of nitrate of silver 
(gr. xx to Jj) should be applied once or twice a day by a brush to 
the aphthous patcnes. Under this treatment the disease soon yields. 

Aphthous ulcers of the mucous membrane of the lips and tongue are 
frequent concomitants of skin disease caused by vegetable parasites. I 
have frequently observed them in persons affected with dermmycosis 
circinata (herpes circinatus)* The fungus represented in fig. 68 is 



488 



MERCURIAL SALIVATION. 



from a case in which the external disease was confined to two large 
semicircles on the upper lip. On the tongue were two aphthous ulcers, 
both near the tip, one was quite depressed, as if partially cicatrised, and 
extended into the vascular corium. The epit helium forming the margins 



Fig. 6*. 



Ffe. 69. 





of the ulcers was opaque and thick and contained the fungus. All 
parts of the mucous membrane are liable to be affected by vegetable 
parasites, and especially when the vital powers of the individual are 
depressed, as in the last stages of lingering diseases. The specimen 
of Oidium albicans represented in fig. 69 is from the kidney of an aged 
patient who came under my care in King's College Hospital. She was 
admitted in the last stage of pulmonary consumption ; her nervous 
power was much depressed, as was indicated by apathy and low tem- 
perature of body. The parasite had invaded the va=cular tissue of the 
mamilla for the distance of about a line between the terminations of 
the tubules. The patient had no cutaneous disease. The vulva and 
nipples are very liable to the aphthous affection. 



4. STOMATITIS MERCURIALIS MERCURIAL SALIVATION. 

Symptoms. — A disagreeable brassy taste, looseness of the teeth, 
tenderness of the gums, a peculiar fcetor of the breath, and a constant 
profuse discharge of saliva, with shieds of epithelium ; shooting pains 
in the face, stiffness of jaw, and swelling of the parotid and submaxil- 
lary glands. The gums are first marked by a distinct red line, and 
then become generally red and swollen ; little ashy superficial ulcers 
appear upon them, and they are apt to bleed ; after a few days, pus 
oozes from their margins here and there, and they are more or less 
separated from the teeth. The inflammation may extend to the interior 
of the cheeks and to the tongue, which then becomes swollen, indented 
by the teeth, and furred; and it sometimes proceeds to ulceration of 
the gums and cheeks, and, in rare cases, to gangrene. These local 
symptoms are accompanied by slight irritative fever. 



STOMATITIS GANGRENOSA. 489 

The duration of mercurial salivation, in slight cases, is two or three 
days; in severe cases, ten days or a fortnight; and if ulceration or 
gangrene ensue, still longer. Several weeks often elapse before the 
gums are restored to their healthy state. 

Causes. — The accumulation of mercury in the system from internal 
administration or external application of some of its compounds. 

Some persons are exceedingly susceptible of mercury, while others 
are with difficulty brought under its influence. Great vigilance is 
therefore required in its use. Severe stomatitis, with slight ulceration 
and bleeding of the gums, swelling of the salivary and cervical glands, 
and severe pain in the jaws, may be induced in three days by the infric- 
tion of^lOO grains of mercurial ointment into the groins, and the 
internal administration of gr. iiiss. of calomel in divided doses. A 
similar condition may be induced by the repeated application of the 
ung. hyd. oxidi rubri to an extensive ulcerated surface. 

Diagnosis. — In most cases, mercurial salivation is distinguished 
from that of pregnancy, that produced by preparations of antimony, cop- 
per, arsenic, and gold, by digitalis, prussic acid, and iodide of potassium, 
and by several other substances, by the excessive fcetor of the breath. 

Treatment. — Gargles of alum, zinc, chloride of soda, chloride of 
lime, tannic acid, hydrochloric acid, acetate of lead, or brandy and 
water. In more severe cases, and when the gums are ulcerated, a 
strong solution of nitrate of silver (Form. 182), applied by a brush, or 
nitrate of silver, or sulphate of copper in substance. If much swelling 
of the glands be present, leeches to the jaws, followed by blisters 
behind the ears, and warm fomentations ; and if there be much irrita- 
tion, opium. Saline aperients, and moderate doses of quinine with acid, 
complete the treatment. 

5. STOMATITIS GANGRENOSA — GANGRENE OF THE MOUTH. 

Synonyms. — Cancrum oris ; Noma. 

Symptoms. — The attention is often first called to a circumscribed- 
indolent, hard, shining swelling on one cheek (generally the left)? 
without pain, heat, or redness. On examining the mucous membrane 
of the mouth, one or more ulcers, blisters, or white eschars, will be 
found on the internal surface of the cheek, lips, or gums. These gradu- 
ally increase in size, and discharge a dirty, sanious, offensive fluid ; at 
the same time the saliva, increased in quantity, flows from the mouth 
mixed with membranous shreds. The swelling of the cheek increases 
till it involves the eyelids and lips. A dark livid spot now occupies 
the centre of the swelling, enlarges, softens, and sloughs. Gangrene, 
having set in, makes rapid progress both within the mouth and on the 
surface, and at length involves the cheek, lips, and gums, and in ex- 
treme cases the nostrils, eyelids, neck, and pharynx ; the teeth fall out, 
and the bones of one or of both jaws, and even the cheek and frontal 
bones, are ultimately attacked. The constitutional symptoms by no 



490 GANGRENE OF THE MOUTH. 

means keep pace with the severity of the local affection. In most cases 
there is no fever, no loss of appetite, and little impairment of strength. 
The little patient often continues to run about and play, to sit up, and 
to amuse himself, till within a short period of his death, the faculties of 
the mind remaining intact. More rarely the local symptoms are 
accompanied by fever. Still less frequently the child becomes delirious. 
Eecovery is indicated by reaction. 

Death results from asthenia, of which the disease is the outward in- 
dication. 

Complications. — Pneumonia f oS cases in 63); pleurisy; enteritis; 
gangrene of the lungs, pharynx, oesophagus, and stomach ; gangrene of 
the extremities, and of the vulva : scrofulous affections. 

Causes. — Predisposing. Inflammation of the lungs, or intestines ; 
childhood, and all causes of debility. — Exciting. The animal poisons 
w T hich produce measles ; small-pox ; scarlatina, &c. ; pneumonia ; con- 
genital syphilis. 

Diagnosis. — From gangrenous aphthae, by these being confined to 
the secreting follicles of the mucous membrane, by their number, small 
size, and slow course, and the absence of cutaneous swelling. From 
malignant pMstule (a gangrenous affection of the skin unaccompanied 
by any disease of the mucous membrane), by the absence of the fever 
which precedes that affection. From anthrax, by the absence of acute 
pain and inflammatory symptoms. Anthrax is very rare on the cheek. 
From most cases of scurvy, by that disease being confined to the gums. 
From the effects of mercury, by the history of the case, by the swollen 
gums and tongue, the abundant flow of saliva, the peculiar odour of 
the breath, and the numerous superficial ulcerations. The diagnosis is 
very difficult when either affection is of some standing, and the previous 
history obscure. 

Prognosis. — Extremely unfavourable. Mortality about 75 percent. 
An early age, previous great exhaustion, and treatment postponed till 
the gangrene has fairly set in, are unfavourable circumstances. 

Treatment. — I. The local treatment consists in the use of stimu- 
lating applications. Previous to the appearance of the livid spot, stimu- 
lating embrocations, such as the linimentum camphorse compositum, or 
the linimentum ammonise, to the cheek, or chloride of soda or of lime 
mixed with water to the consistence of a stiff paste, or the muriatic or 
pyroligneous acid, or lunar caustic. Should gangrene have set in, strong 
acetic or nitric acid. When the eschar has separated, the chloride of 
soda or the chloride of lime in solution, or the weaker acids, may be 
resumed. 

II. The general or constitutional treatment, will be determined by 
the previous history and actual condition of the patient. Pure air, 
scrupulous cleanliness, and nourishing dit-t, are obviously indicated in 
all cases. Beef-tea. thickened with arrow-root, arrow-root made with 
milk, calf 's-foot jelly, and wine diluted with water, or added to nourish- 
ing articles of food, should be freely and frequently administered. 



GINGIVITIS — GLOSSITIS. 491 

Quinine in the diluted acids, or in wine, and carbonate of ammonia, are 
the best medicines. 

If constipation be present, compound rhubarb or jalap powder, fol- 
lowed by castor-oil or saline aperients, must be given, as often as 
requisite. Diarrhoea must be checked by the pulv. cretac aromaticus 
c opio, or other suitable remedies adapted to that disorder, especially 
injections of starch and opium ; pneumonia, if present, by opium, with 
full doses of liquor ammonias acetatis. 



GINGIVITIS— INFLAMMATION OF THE GUMS— PAINFUL 
DENTITION. 

Symptoms. — Dentition is generally accompanied by salivation ; a red, 
hot, painful, and swollen state of gum. The infant puts its fingers, or 
whatever it can grasp, into the mouth, and presses the gums upon it. 
But when true inflammation is present, the child will not bear even the 
pressure of the nipple. This intense inflammation of the gum may extend 
to the lining membrane of the mouth, and be followed by ulceration, 
followed by aphthae, or gangrene. 

The general symptoms are feverishness, fretfulness, disturbed sleep, 
determination of blood to the head, often accompanied by diarrhoea and 
colic; and inflammation of the brain or its coverings. In extreme cases, 
water in the head, with convulsions, inflammation of the lungs, or 
laryngismus stridulus. Skin diseases are also common complications, 
especially lichen and strophulus. 

Treatment. — In mild cases, gentle friction of the gums; in more 
severe cases, scarification. Warm bath, simple diet, and a strict atten- 
tion to the state of the bowels, complete the treatment. The attendant 
diseases must be treated on general principles. 

Incision of the gums ought not to be practised unless they are swollen, 
hot, and painful from the pressure of the teeth. When the incision is 
made prematurely, the eruption of the tooth, so far from being acce- 
lerated, is retarded. The incisions should be deep and free. One incision 
should be made parallel to the alveolar margin ; and a second transverse 
to the first. 

The gums are subject to swelling, ulceration, and gangrene, both in 
infants and adults. In the adult, they are generally parts of other 
diseases, such as scurvy, or mercurial salivation ; in young children, 
they are commonly idiopathic. 



GLOSSITIS— INFLAMMATION OF THE TONGUE. 

Symptoms. — Inflammation of the whole tongue is rare, except as the 
sequel of profuse salivation, or of strong irritant applications. More 
commonly it is of limited extent, appearing at first as a hard tumour on 
the upper surface, which suppurates slowly, and leaves a deep ulcer, 



492 ACUTE TONSILLITIS. 

sometimes penetrating the tongue. It arises, in most instances, from 
gastric or intestinal irritation, and is cured by purgatives and the appli- 
cation of nitrate of silver. 

Inflammation of the whole tongue is often a severe and dangerous 
disease, marked by heat, swelling, and pain, difficult speech and deglu- 
tition, dyspnoea, salivation, swelling of the veins of the neck, and detei- 
mination of blood to the head, with inflammatory fever. 

Terminations. — In resolution, suppuration, or gangrene. In ex- 
treme cases it threatens suffocation or apoplexy. 

Causes. — Mechanical injuries; strong irritants; the sting of insects; 
salivation ; extension of diseases affecting the tonsils, gums, and cheeks. 

Treatment. — In the early stage, local depletion, according to the 
severity of the symptoms, with brisk purgatives and antiphlogistic 
remedies, with ice to the surface of the tongue. In a more advanced 
stage, incisions. If suffocation threaten, tracheotomy must be per- 
formed. 

Ulceration sometimes takes place on the side of the tongue, from the 
irritation of a decayed tooth, which must be filed or removed. 

Epithelial cancer of the tongue is known by its peculiar hardness, 
the irregular ulceration, the acute lancinating pain, and the cachectic 
state of the patient. 

Syphilitic ulcers of the tongue, with foul surface and irregular 
hard margins, occupying chiefly its edges, require a course of mercury 
or iodide of potassium, with the application of solid sulphate of copper, 
or nitrate of silver. 



TONSILLITIS— INFLAMMATION OF THE TONSILS. 

1. ACUTE TONSILLITIS. 

Synonyms. — Cynanche tonsillaris. Angina tonsillaris. Amygda- 
litis. Quinsey. Inflammatory sore throat. 

Symptoms. — After rigors, followed by flushes, pains in the back and 
limbs, and a full, frequent, and compressible pulse, — a sense of fulness, 
heat, and dryness in the throat, pam and difficulty in swallowing, and 
speaking. The throat presents a diffused redness, of a deeper tint over 
the tonsils, which are swollen, and sprinkled with greyish-yellow spots 
consisting of secretion from the gland blocking up the mouths of its 
follicles. The tongue is coated with a white creamy fur. As the disease 
advances, the swelling of the tonsils increases; the acts of swallowing 
and speaking become more difficult and painful ; liquids return through 
the nostrils, there is a constant discharge of viscid saliva, the respiration 
is affected, and there is a painful sense of tension, with acute darting 



CHRONIC TONSILLITIS. 493 

pains in the ears. The febrile symptoms increase in severity, and the 
pain in the back and limbs becomes more acute ; but in a more advanced 
stage, the fever often subsides, or changes its character from inflam- 
matory fever during the first stage, to mild hectic during the stage of 
suppuration. 

Duration. — From five to seven days. 

Terminations. — By resolution, suppuration, ulceration, or gan- 
grene ; or in chronic enlargement. 

Prognosis. — The disease usually term-inates by resolution. Suppu- 
ration is to be feared when the disease does not yield to remedies, when 
the local pain is acute and throbbing, or when there are rigors or cold 
shiverings. An abscess is indicated when there is much swelling, a 
sense of fluctuation on pressure with the ringer, a whiteness of some 
part of the tumour, and, finally, purulent expectoration. Gangrene is 
to be dreaded, if the fever be intense, and the pain extremely violent, 
without any sign of resolution or suppuration. A pinched and sunken 
countenance, the extremities cold and covered with a clammy perspira- 
tion, a small, frequent, weak, and intermittent pulse, and a very foetid 
odour issuing from the mouth, are signs of its existence. 

Causes. — Predisposing. Youth, debility, syphilis, previous attacks. 
— Exciting. Cold ; cold drinks while the body is heated ; the deglutition 
of acrid or stimulating substances. 

Treatment. — When the disease is slight, the treatment proper to 
catarrh. When more severe, the tonsils should be scarified and leeches 
applied below the angles of the jaws, followed by a mustard poultice to 
the throat, and a brisk aperient. When, however, the gland suppurates 
and feels tense and yielding, a lancet should be thrust directly backwards 
into the most prominent part, and the pus evacuated. The mouth 
should then be gargled repeatedly with warm water. When the tonsils 
are so swollen as to impede the breathing, emetics sometimes give relief. 
If the skin be hot and the pulse strong, saline diaphoretics should be 
given ; but if the patient is very weak, quinine, beef-tea, and wine, must 
be prescribed. 

2. CHRONIC TONSILLITIS. 

Symptoms. — Enlargement and induration of the tonsils, which, pro- 
jecting towards the middle line, impede deglutition, vocalization, and 
hearing. The mouth is often kept partially open ; the respiration is 
audible and the voice sibilant. 

Causes. — Predisposing. Syphilis, scrofula, and chronic dyspepsia. 
— Exciting. Acute inflammation of the gland. 

Treatment. — General. Chalybeate tonics with iodine, change of 
air, warm clothing, — Local. Strong solution of nitrate of silver, 
astringent gargles (Form. 203), occasional application of a leech or 
small blister to the angles of the jaws. Iodine unguents and liniments. 



494 PAROTITIS. 

When the above remedies are unavailing, and the tonsils are of such a 
size as to impede deglutition or respiration, or to affect the voice, ex- 
cision may be practised. 

Ulceration of the tonsils may occur in disordered states of health, 
but it is generally a secondaiy effect of syphilis. The disease is slow 
in its progress ; but, if not checked, it extends into the nostrils and 
fauces, and ultimately attacks the larynx itself. A gargle of chloride 
of soda may be used with advantage, and the ulcers may be frequently 
touched with nitrate of silver. The general health must be carefully 
attended to, and the strength be supported by a nourishing and ge- 
nerous diet. Syphilitic ulceration of the tonsils requires the same 
treatment as other secondary diseases. 

The disease known as " Clergyman's sore throat'' or " dysphonia 
clericorum" consists at first in a chronic enlargement of the tonsils and 
lengthening of the uvula, with a relaxed and congested condition of the 
mucous membrane of the fauces, which gradually extends to the 
pharynx and upper part of the larynx. In the most severe cases of the 
disease, there is also ulceration of the mucous follicles of the parts 
affected, and the mucous membrane, especially about the pillars of the 
fauces, is coated with a tenacious secretion. The symptoms are dryness 
and tickling of the throat, constant hawking and spitting, and hoarse- 
ness increased after reading or speaking, and attended sometimes with 
pain in the upper part of the windpipe. The disease is generally 
traceable to a bad habit of reading and speaking in unhealthy persons. 
The treatment consists in the exhibition of alteratives and tonics to 
improve the general health, the particular remedies employed being 
determined by the state of the system ; and in local measures directed 
to remove the relaxed and congested state of the mucous membrane. 
The best local remedy is a strong solution of nitrate of silver (g\\ v to 3J) 
applied, by means of a camel's-hair brush or a piece of sponge, to the 
whole of the inflamed surface. If this mode of application should 
prove insufficient, the solution of nitrate of silver may be applied to 
the upper part of the larynx by means of a whalebone probang tipped 
with sponge. When there is great enlargement of the tonsils of long 
standing, excision may become necessary, as in simple chronic tonsillitis. 
Clergymen suffering in this way should be directed to take a full breath 
very frequently while reading or preaching, so as to speak from the 
lung;s and not from the throat; and to take lessons in elocution. 



PAROTITIS— CYXANCHE PAKOTIDEA— THE MUMPS. 

Symptoms. — After slight febrile symptoms, fulness and soreness at 
the angle of the jaw, with pain on moving the part. The swelling 
extends by degrees upwards to the space between the cheek and ear, and 
downwards to the submaxillary gland, occasioning great deformity. 
On the fourth day it begins to subside. It is generally confined to one 



BE0XCH0CELE. 495 

side, but sometimes it attacks the other afterwards ; it rarely attacks 
both sides at once. The disease is sometimes accompanied, and some- 
times followed, by painful swelling of the breasts or testicles. It ge- 
nerally terminates in resolution. 

Suppurative inflammation of the parotid is a frequent concomitant 
of the latter stage of typhus and enteric fevers. The inflammation is 
often developed with remarkable rapidity. Without any premonitory 
indication, a large congested, very hard and painful swelling forms 
round the ramus of the jaw in a few hours ; and the inflammation 
rarely stops short of suppuration. 

Causes. — Predisposing. The period of childhood. — Exciting. Expo- 
sure to cold ; scarlatina, and other febrile diseases. 

Coxtagion. — A medical student had mumps in London, while his 
mother was staying with him. They remained in town until the 
swelling disappeared, and then went 100 miles into the country. There 
was no mumps in the neighbourhood ; but a fortnight after their arrival 
one of the children was taken ill with it, and it afterwards successively 
affected, at regular intervals of a fortnight, each member of a large 
family. 

Treatment. — Warm fomentations, with the application of flannel 
in the intervals ; gentle aperients and farinaceous diet. If much in- 
flammation be present, leeches may be applied. The secondary affection 
of the breasts or testicles must be treated in the same way. Should 
any swelling remain after the inflammation has subsided, friction with 
stimulating liniments may be prescribed. 



BRONCHOCELE— CYXAXCHE THYROIDEA— GOITRE. 

Symptoms. — A swelling affecting the entire thyroid gland, or a 
single lobe of it ; at first firm and elastic, but after a time soft, with 
flabby, small portions of a denser consistence. It grows slowly at first, 
but after a time rapidly, extending upwards towards the jaw, laterally 
beyond the limits of the neck, and even hanging over the chest. It 
sometimes attains an enormous size, and then causes serious inconveni- 
ence by its pressure on the trachea and vessels of the neck. 

Morbid Anatomy. — Hypertrophy of the gland, partial or entire, 
with enormous enlargement of its vesicles, so as to present, when cut 
into, cavities often of considerable size, and containing fluids of various 
character and consistence. 

Causes. — Predisposing. Female sex ; puberty ; hereditary ten- 
dency. — Exciting. Unknown. The disease is endemic in localities 
differing widely from each other in all respects. But the most common 
characteristic of the spots in which it prevails is want of due movement 
of the air. It is very common in deep valleys shut in by mountains. 
Combined with every degree of idiocy and imbecility it is the Cretinism 



496 OESOPHAGITIS. 

of the Vallais. It is so common in Derbyshire as to be called the 
" Derbyshire neck." It is also common in the valley of the Teme, and 
the dale of the Corve, N.W. of Ludlow, particularly in the vicinity of 
the calcareous beds of the Silurian and Devonian formations. 

Treatment. — Iodine externally. Iodide of potassium internally. 
Burnt sponge, which contains minute quantities ot iodine, was formerly 
in great repute for the cure of this malady. Kemoval from the district 
in which the disease originated. 

When other means fail, and the tumour, by its pressure, causes great 
inconvenience, ligature of the thyroid arteries. 



DISEASES OF THE (ESOPHAGUS. 

OESOPHAGITIS— IN PLAMMATION OF THE (ESOPHAGUS. 

Svmptoms. — Pain, or a burning sensation, in the act of swallow- 
ing, either in a pait of the oesophagus, or through its whole extent. 
This pain is sometimes increased on pressing the larynx firmly towards 
the spine. When the inflammation extends to the mucous membrane 
of the stomach, there is pain in the epigastrium, with vomiting, leading, 
in some instances, to the expulsion of tenacious casts of the tube. In 
cases produced by swallowing hot water or corrosive poisons, large 
flakes of epithelium are often discharged. 

Causes. — Stimulant and corrosive applications to the tube itself, 
such as hot water, and the several corrosive poisons. The extension of 
inflammation from the mouth, fauces, or tonsils ; wounds. 

Treatment. — The frequent use of ice or iced water, and a farina- 
ceous liquid diet. So long as the difficulty of swallowing remains very 
great, the patient must be supported by nutritious injections. After 
the first or second week a large well-oiled bougie should be carefully 
passed daily, in order to prevent constriction during cicatrization. 



OTHER DISEASES OF THE (ESOPHAGUS. 

The gullet is subject to other functional and structural diseases, 
among the former of which may be mentioned rheumatism and spas- 
modic stricture ; among the latter, hypertrophy of the submucous tissue, 
and various malignant degenerations, such as scirrhus and medullaiy 
sarcoma. It is also liable to pressure from aneurism of the aorta or 
carotid artery, from enlargement of the cervical glands, and from diseases 
of the spine. 

Rheumatism of the gullet is a rare disease, characterised by painful 
deglutition distinctly referred to some part of its course, accompanied 
by rheumatism of other muscles, and yielding to the treatment proper 
to muscular rheumatism. 



DISEASES OF THE STOMACH— CONGESTION. 497 

Spasmodic stricture of the gullet is characterised by difficulty of 
swallowing, accompanied by a sense of choking, the food either passing 
into the stomach after many efforts to swallow, or being rejected. It 
is generally associated with other symptoms of hysteria, and is amenable 
to the treatment proper to that disease. It is distinguished from 
organic stricture by the circumstance of its not being constant, but- 
subject to intermissions ; by the result of an examination with a bougie ; 
by the history of the case ; and the presence of other hysterical symp- 
toms. It requires no local treatment ; but in obstinate cases, the daily 
introduction of a bougie may be attended with benefit. 



DISEASES OF THE STOMACH. 

Congestion . . . . Of the Stomach. 

ELematemesis . . . Vomiting of Blood. 

Gastritis Inflammation of the Stomach. 

Ulcer ...... Of the Stomach. 

Perforation, . . . Of the Stomach. 

Carcinoma .... Of the Stomach. 

Other Forms op Stomach Disorder. 

CONGESTION OF THE STOMACH. 

Symptoms. — Congestion of a gland entails a diminution of its ap- 
propriate secretion. The mucous membrane of the stomach is an ex- 
tended and highly vascular glandular surface, and when it becomes 
congested the secretion of gastric juice takes place slowly, and is dimin- 
ished in quantity. Anorexia, dyspepsia, with a dryish tongue and thirst, 
and more or less constipation, are therefore the necessary results of con- 
gestion. 

The distended capillaries are occasionally relieved by an oozing of blood. 
The effused blood is acted on by the acid secretion of the stomach, 
and coheres in black coagula, which may be rejected by vomiting, con- 
stituting Jicematemesis ; or the clots undergo disintegration in the 
stomach, and are rejected as " coffee-ground " or " black " vomit ; or 
they may pass along the alimentary canal, and, after further alteration, 
be ultimately evacuated as a black grumous or pultaceous stool, con- 
stituting melcena. 

Some pain and tenderness in the epigastrium are generally associated 
with congestion of the stomach. 

Causes. — 1. Obstruction to the flow of blood through the liver and 
thoracic viscera. If a ligature be placed around the portal vein, or the 
vena cava? inferior at the under surface of the diaphragm, blood will 
ooze from the stomach as a necessary consequence. Some diseases of 
the liver cause so much obstruction to the portal circulation that they 
are almost tantamount to a ligature so placed ; and obstructions to the 
flow of blood through the lungs and the heart are nearly equivalent in 

2 K 



498 H^MATEMESIS. 

their effects on the stomach to obliteration of the inferior cava above 
the liver. Hence congestion of the stomach is sooner or later a promi- 
nent symptom in cirrhosis of the liver ; in atrophy from long-con- 
tinued obliteration of the bile ducts ; and in diseases, such as cancerous 
tumours, which involve and press upon the portal vein. Acute sup- 
pression of bile, as occurs in yellow and relapsing fevers, commonly 
produces severe congestion of the stomach, resulting in vomiting of 
altered blood. The disease of the lungs which most frequently leads 
to congestion of the stomach is emphysema ; and disease of the mitral 
valve, which at the same time contracts its orifice and permits regurgi- 
tation, is the condition of the heart which most commonly produces the 
same result. 

Congestion of the stomach may also be due to functional disorder. 
When the sexual organs fail to perform the menstrual function, the 
stomach sometimes assumes a vicarious office, and a monthly haemate- 
mesis takes the place of the catamenia. In some cases this habit is 
retained during the whole natural term of menstruation. 

Treatment. — This must be directed to the cause of the disease, 
and we must relieve the congestion of the portal circulation by free 
watery purgation induced by the non- irritating saline purgatives, such 
as potassio-tartrate of soda. The abdominal circulation generally will 
also be relieved by copious diuresis, to affect which acetate and nitrate 
of potash may be prescribed. In order to prevent the congestion from 
degenerating into inflammation and ulceration, irritating food and 
medicine and strong alcoholic drinks, and even fermented liquors, must 
be avoided, and the diet must consist chiefly or exclusively of eggs, 
milk, and farinaceous articles. If there be much pain in the epigastrium, 
mustard poultices may be applied, and a few leeches to the anus. In 
cirrhosis of the liver it is better to avoid leeching, for the bleeding is 
liable to be too free. 

Haematemesis, if present, must be treated as recommended below. 



ILEMATEMESIS— VOMITING OF BLOOD. 

Symptoms. — Vomiting of dark-coloured clotted or grumous blood in 
greater or less quantity, often mixed with food, and preceded by a 
sense of weight and obtuse pain in the region of the stomach. If the oozing 
be continuous, the countenance becomes blanched ; but if rapid and con- 
siderable, the patient becomes pale, faint, and sick, and the vomited 
blood may be bright-coloured. In hepatic disease the complexion is 
sallow, and the conjunctiva of the eyes tinged with bile. 

Causes. — Those of congestion of the stomach ; ulcer of the stomach ; 
rupture of an aneurismal tumour into the stomach. 

Morbid Anatomy. — Congestion, ulcers, or malignant disease of the 
stomach : congestion or chronic disease of the liver. 



GASTRITIS. 499 

Diagnosis. — From haemoptysis ; by the rejection of the blood by 
vomiting, not by coughing ; by the presence of food ; by the discharge 
of a large quantity of dark blood more or less altered. Blood which 
comes from the lungs, except when discharged from old cavities, is 
always fluid and of a bright vermilion colour. But in certain rare 
cases, the diagnosis of the source of the haemorrhage is not easy. If, 
for example, an ulcer of the stomach erode a large arterial trunk, the 
blood rejected from the stomach may be fluid and scarlet. Again, the 
blood of haemoptysis may come up into the mouth without the effort of 
coughing, and may seem to be vomited rather than coughed up. It 
may also be unmixed with sputa ; and when discharged from old cavi- 
ties of the lungs, may have lost its bright vermilion hue. But the 
discharge of a very large quantity, such as a pint, or a quart, of dark 
grumous blood, even though unmixed with food, may be held to be 
conclusive of its having come from the stomach ; for when such large 
quantities are expelled from the lungs, the blood is always of a bright 
vermilion colour. The state of the liver and lungs will serve to con- 
firm the diagnosis. 

Treatment. — Rest, abstinence from food for some hours, and after- 
wards a bland farinaceous diet. 

When the haemorrhage is excessive, the patient maybe made to drink 
freely of iced water, or to swallow rough ice, and poundecl ice may be 
applied to the pit of the stomach. The vegetable and mineral astrin- 
gents (Form. 173). When the haemorrhage has been stayed, gr. v 
pilulae hydrargyri, followed by a saline aperient, should be given, and 
the disease subsequently treated according to its cause. 

If there be suppression of the haemorrhoidal or catamenial flux, leeches 
should be applied to the anus or vulva, together with other remedies 
appropriate to those diseases. 

When the disease occurs in delicate or scorbutic habits, tonics and 
quinine, with the mineral acids, are indicated. 



GASTRITIS— INFLAMMATION OF THE STOMACH. 

1.. ACUTE GASTRITIS. 

Symptoms. — An acute fixed pain and sense of burning heat in the 
pit of the stomach, increased by pressure, deglutition, and the move- 
ments of respiration ; frequent vomiting of clear viscid mucus streaked 
or not with blood, attended with increase of pain ; intense thirst ; great 
restlessness, and extreme anxiety ; the tongue red ; the pulse quick, 
small, and hard ; the bowels confined. 

The disease generally extends to the gullet and intestines, and is 
attended by pain and dysphagia, diarrhoea, and abdominal tenderness. 

Terminations. — In resolution, when the pulse becomes more soft 
and full, and the other symptoms gradually disappear. In chronic 



500 SUB-ACUTE GASTRITIS. 

gastritis. In gangrene, marked by a violent exacerbation of the symp- 
toms, followed by a sudden cessation of pain, a rapid and intermitting 
pulse, the utmost prostration of strength, cold extremities, delirium, 
hiccup, and death. In perforation, characterised by sudden and acute 
pain, with extreme prostration, and symptoms of peritonitis. 

Causes. — Drinking ardent spirits or hot water ; irritant poisons, 
and indigestible diet. Idiopathic acute gastritis is exceedingly rare. 
Prolonged abstinence from food. The gouty excitant in the blood. 

Diagnosis. — From enteritis, by the epigastric heat, tenderness, and 
pain, and by the more severe vomiting. 

Prognosis. — Favourable. The pulse becomes softer, fuller, and less 
frequent; and the pain and tenderness gradually ceases. — Unfavour- 
able. No alleviation of symptoms. Extreme and general tenderness of 
the abdomen. Symptoms marking the accession of gangrene or per- 
foration. 

Morbid Anatomy. — The mucous membrane of the stomach red, 
universally or in patches, especially around the cardia and pylorus ; 
deep redness of the rugae; abrasion, ulceration, or " hsemorrhagic 
erosions," occurring as brown or soot-black spots, from the size of a pin's 
head to that of a pea ; or softening of the membrane ; gangrene ; also 
dark patches resembling gangrene, but arising from the effusion of 
blood into the sub-mucous cellular tissue ; the blood-vessels full of dark 
blood. Gangrene and ulceration are rare, but softening is common. 

Treatment. — I. The free application of leeches to the anus and pit 
of the stomach. Iced water or ice, externally and internally. Free 
action of the bowels in the absence of diarrhoea, by the use of emollient 
clysters. By the free and frequent use of mucilaginous diluents, such as 
gruel, linseed-tea, or barley-water. 

II. The sickness, restlessness, and pain are best relieved by soda- 
water and small doses of dilute hydrocyanic acid (Tr\iii to TT)v) com- 
bined with tincture of opium. 

2. SUB-ACUTE GASTRITIS— DYSPEPSIA — INDIGESTION. 

Symptoms. — Want of appetite ; nausea ; flatulence ; heartburn ; 
occasional pain in the epigastrium ; sick headache ; a sense of fulness 
and oppression after eating, or a feeling of languor and depression 
relieved by taking food. These symptoms, variously combined, and 
generally accompanied by constipation, diarrhoea, or the two conditions 
alternately, and with defective or immoderate secretion of bile, constitute 
the most common form of dyspepsia. A dry cough ; cold extremities ; 
headache ; furred tongue, with red prominent papilla? ; a bitter taste ; 
dimness of vision ; bright spots before the eyes ; palpitation ; shooting 
or fixed pains in the region of the heart, and under the scapula?, varying 
with the degree of flatulence, are occasional consequences of dyspepsia. 
In the more severe cases the epigastric pain is considerable, and is in- 
creased by pressure and by food. Sometimes the least food produces 



DYSPEPSIA. 501 

pain, and it is rejected as soon as it is swallowed, or after a short 
interval. Pain in the stomach (gastralgia) may be produced by flatu- 
lent distension, and by the presence of hard indigestible food, or of excess of 
acid. When the pylorus contracts upon masses of hard undigested food 
as it is passing into the intestines, violent crampy pain in the epigas- 
trium is produced. 

Causes. — Predisposing. Debility ; want of exercise ; depressing 
passions ; amenorrhea ; imperfect mastication ; too short or too long in- 
tervals between meals ; the abuse of drastic purgatives ; close study, or 
exercise immediately after food ; diseases of the liver, pancreas, or spleen ; 
the gouty diathesis. Dyspepsia is a frequent precursor of phthisis, and 
a common accompaniment of asthma and bronchitis. — Exciting. In- 
activity of the liver producing constipation ; unwholesome and indi- 
gestible food ; the abuse of spirituous liquors, especially at the dinner- 
table ; liquids in excess, especially hot tea and coffee. 

Diagnosis. — From ulcer of the stomach, by the absence of a fixed 
and limited seat of pain and of haematemesis. 

Treatment. — Indications. I. To correct any bad habits, and to 
regulate the diet. II. To restore the stomach to a healthy condition. 
III. To palliate urgent symptoms. 

The habits which commonly require correction are the following : — 
Eating too much at one time ; eating too often or too seldom ; taking 
too great a variety of food at the same meal ; drinking too much liquid 
before or with the meals ; imperfect mastication ; resuming bodily or 
mental occupation directly after eating ; indolent and sedentary habits ; 
the injudicious use of purgatives ; drinking, smoking, chewing tobacco, 
opium-eating, and tea and coffee in excess. If any particular article of 
food seem to disagree, it should be carefully avoided. Flatulence is fre- 
quently increased by green vegetables and fruit. Wine and ale will 
sometimes require to be exchanged for weak brandy and water, or for 
brandy with soda-water, or Seltzer water. 

II. A regular action of the bowels should be brought about by mild 
cholagogue purgatives. Stomachic tonics, such as gentian, calumba, 
cascarilla, and cinchona, combined, according to the state of the secre- 
tions, with alkalies or the mineral acids, should be persevered in. A 
few grains of compound rhubarb-pill may be given as a dinner-pill in 
mild cases. 

III. If there be tenderness, half a dozen leeches or a mustard poultice 
may be applied to the epigastrium. Acidi hydrocyanici cliluti, VC\y, 
tincturae opii, ff\v, given in effervescence, with a few grains of carbon- 
ate of soda and citric acid, will generally allay the vomiting. The 
diarrhoea will generally yield to a few doses of the pulvis cretse aroma- 
ticus cum opio. 

An acute attack of indigestion is best treated by an emetic, followed 
by 1 est and a free aloetic purge. 



( 502 ) 



ULCER OF THE STOMACH. 

Symptoms. — Pain in the pit of the stomach, referred to a small spot, 
coming on immediately or soon after food, continuing for an hour or 
two, and then slowly abating as the stomach becomes empty. A cir- 
cumscribed soreness in some part of the epigastrium is usually induced 
by pressure. Circumscribed pain is also commonly felt in the corre- 
sponding part of the back. It is increased by indigestible food, hot 
fluids, and alcoholic liquids, and in young females on the approach of 
the menstrual period. There is nausea and vomiting of food, of a clear 
sour liquid, of bile, of blood. Sometimes the blood is discharged by the 
bowels, which are generally constipated. The patient loses flesh, has 
an unhealthy aspect, and wears an expre.-sion of wearine-s and suffering. 

Usually the disease causes very little constitutional distui bance. and 
in some cases the local symptoms are so slight, that severe haematemesis, 
or even perforation of the stomach, may be the first indication of the 
disease. In some cases the piocess of ulceration is rapid, and perforation 
may occur within a few weeks of the foimation of the ulcer. In other 
cases the ulcer remains open for many years, giving rise to its ordinary 
symptoms, and now and then to an alarming haemorrhage ; and at last 
leads to perforation. 

Terminations. — In recovery; in perforation (see p. 504); by 
haemorrhage and fatal syncope, or collapse ; by marasmus from constant 

vomiting. 

Causes. — Predisposing. The female sex ; intemperance ; fatigue ; 
anxiety. The influence of age may be thus briefly stated: — From 16 
to 20 years of age, 20 cases ; for each decade from 20 to 60, about 50 
cases ; for the two decades from 60 to 80, about 80 cases ; and for the 
10 years from 80 to 90, 100 cases. In this country it is supposed to 
be most frequent in maid-servants, between the age of 18 and that of 
25. (Budd v — Exciting. Obscure. 

Diagnosis. — From dyspepsia, sub-acute gastritis, pyrosis, and 
gastralgia, by the limited pain on pressure in the epigastrium ; by the 
pain in the back, the more frequent vomiting, and the discharge of 
blood ; from pyrosis and from cancer of the stomach, by the shorter 
course of the latter, the marked cancerous diathesis, the lancinating 
pain, the presence of a hard and moveable tumour in the pit of the 
stomach, the less abundant haemorrhage, and the presence of cancer-cells 
in the vomit. The diagnosis of ulcer of the stomach is often difficult 
and uncertain. 

Prognosis. — Favourable but guai ded. Alost guarded with young 
females in whom perforation is a common event. About one in five 
cases commonly prove fatal in one of the ways mentioned above. 

jSIorbid Anatomy. — The returns of the hospital at Prague give 
a total of 10,203 bodies examined, in which 126 open ulcers and 
224 cicatrices of the stomach and duodenum, = 3*4 per cent., were 






ULCER OF THE STOMACH. 503 

found. In more than a third of the cases the ulcer occupies the 
posterior surface of the stomach ; and more than three-fourths occur on 
the posterior surface, on the lesser curvature, or near the pylorus. In 
about one-fifth of the cases there is more than one ulcer; and there 
may be to two, three, four, five, or more. ' ; The ulcer is rarely much 
smaller than a fourpenny-piece, or larger than a crown-piece ;" but it 
may attain a diameter of five or six inches. Its shape is usually round 
or oval, and it presents the appearance of Ci a shallow but level pit, 
with a sharp, smooth, vertical edge, as though it had been punched 
out " (Brinton) ; but as the circular opening in the sub-mucous areolar 
tissue is smaller, and the aperture in the peritoneum, if the ulcer per- 
forate, still more minute, the ulcer has a conical form. The surrounding 
mucous membrane and areolar tissue are somewhat thickened, and 
sometimes inflamed. Perforation takes place in about 1 case in 8 ; this 
result being often prevented by adhesion to the pancreas, liver, spleen, 
mesentery, or diaphragm. 

In attributing death to ulceration of the stomach, it is important to 
be aware of the fact that, under certain circumstances, the coats of the 
stomach undergo self-digestion, resulting in pulpy or gelatinous soften- 
ing, irregular abrasion, and, ultimately, perforation. The mucous 
membrane is converted into a thin, pasty mucous layer ; the blood- 
vessels are blackened ; and if all the coats of the stomach are removed, 
a ragged aperture results, through which the contents of the stomach 
escape. This self-digestion is due to the action of the gastric juice ; it 
is met with in those who have died suddenly during digestion, and in 
those who have died from disease (such as phthisis), in which chronic 
irritation of the vagus nerve had induced excessive secretion of gastric 
juice. 

Treatment. — I. Our endeavours must be to promote the healing 
of the ulcer, by preventing irritation or distension of the stomach. 
With this view the diet must be strictly regulated. Solid food must 
be rigidly avoided, and its place supplied by milk, eggs in the form of 
emulsion, light broths, and farinaceous diet, given at short intervals, 
and in quantities not exceeding a tea-cupful. Spirituous liquors and 
hot fluids should be forbidden. 

II. If there be much tenderness on pressure, mustard poultices or 
blisters should be used ; if constant pain, solid opium may be given ; 
if gastrodynici and pyrosis, nitrate of bismuth ; if distressing vomiting, 
hydrocyanic acid, and farinaceous food in very small quantities often 
repeated ; if vomiting of blood, small pieces of ice from time to time, 
and the remedies recommended under hsematemesis ; if constipation, 
castor-oil is the most suitable aperient; if diarrhoea, compound kino 
powder. 

III. If the patient be ancemic, the preparations of iron, of which the 
ammonio-citrate is most suitable. (In this disease it may be given 
dissolved in glycerine.) If there be much debility present, the citrate 
of iron and quinine in glycerine is to be preferred. In intemperate 
persons, full doses of opium are indicated. 



( 504 ) 



PERFORATION OF THE STOMACH. 

Symptoms. — After a longer or shorter duration of symptoms of ulcer 
of the stomach, intense pain in the epigastrium occurring suddenly, 
spreading rapidly over the whole abdomen, and soon followed by 
tympanites and collapse. The disease assumes all the characters of 
peritonitis, and usually proves fatal in from twenty-four to thirty-six 
hours ; but in some cases the fatal event is postponed in consequence of 
the peritonitis being limited in extent, or sub-acute in character. In 
most cases the rupture takes place during the distension of the stomach 
by a full meal, but it is sometimes caused by vomiting, straining at 
stool, coughing, or sneezing ; by pressure, shocks, or blows. 

Terminations. — In acute peritonitis and rapid death ; in chronic 
peritonitis, and death after a more considerable interval ; in abscess of 
organs bordering on the stomach, and opening in various ways; in 
gastric fistula. 

Causes. — Predisposing. Those of the gastric ulcer. Females from 
the fifteenth to the twenty-fifth year are very liable to this affection. — 
Exciting. Gastric ulcer ; irritant poisons. 

Diagnosis. — From ordinary peritonitis by the sudden attack. 

Prognosis. — In the highest degree unfavourable, especially when 
the perforation takes place after a full meal. 

Treatment. — The patient should be placed in the recumbent 
posture at perfect rest. A full dose of the extract of opium, or the com- 
pound soap-pill, should be given at intervals of three or four hours. 
Complete abstinence from food must be enjoined, the patient being 
allowed merely to moisten the mouth from time to time. If the 
inflammation run high, leeches should be applied to the abdomen, 
followed by warm fomentations. After the lapse of several days, the 
lower bowel should be relieved by enemata, and nourishment may be 
supplied by the same channel ; but purgatives by the mouth are con- 
tra-indicated. Should the patient survive the immediate consequences 
of the rupture, milk and farinaceous food must be given by the spoon- 
ful at short intervals, and a return to the usual diet must be made 
slowly and cautiously. When convalescent, castor-oil should be used 
as an aperient. 



CARCINOMA, or CANCER OF THE STOMACH. 

Symptoms. — In the early stage the symptoms are very obscure. 
They are usually those of dyspepsia (sub-acute gastritis). But, after 
a longer or shorter interval, during which the patient loses flesh, 
and obtains little or no relief from his dyspeptic symptoms, a circum- 
scribed tumour is discovered in the epigastrium, and now the pain 



ATOXIC DYSPEPSIA. 505 

becomes burning, gnawing, or lancinating ; and there are nausea; acid 
and fetid eructations ; with vomiting of ingesta, of mucus, of blood, or 
of a dark grumous or sour frothy matter containing sarcinse (Fig. 70) ; 
complete constipation, and retraction of the belly, which becomes hard 
and flat ; great emaciation, and the complexion and expression indica- 
tive of the cancerous diathesis. 

When the cancer involves the pylorus, as is most frequently the case, 
the passage of food into the intestine is impeded ; it accumulates in the 
stomach, and ferments. The distended stomach is occasionally relieved 
by copious vomiting. 

Morbid Anatomy. — The disease may take the form of scirrhus, or 
of medullary or colloid cancer. But the most common form is scirrhus, 
and its usual seat the pylorus. The disease is identified by the dis- 
covery of cancer-cells (Fig. 6, p. 81). The stomach is generally con- 
tracted when the disease occupies the cardiac end ; greatly expanded and 
hypertrophied when the pylorus is affected. 

Diagnosis. — The epigastric tumour; lancinating pain ; constipation 
and retraction of the abdomen, the cachexy and emaciation ; the per- 
sistent vomiting of decomposed food, and the rapid progress of the 
malady, serve to identify this disease. Cancer rarely occurs before 
forty. The part of the stomach attacked may be generally inferred 
from the symptoms. When the cardia is affected, the pain and vomit- 
ing come on immediately after taking food ; when the pylorus is 
attacked they come on later. If the cardiac orifice be implicated, there 
will be obstruction to the entrance of food ; if the pyloric, obstruction 
to the exit of chyme. 

Causes. — Predisposing. The cancerous diathesis. — Exciting. Chronic 
dyspepsia. 

Treatment. — A bland and nourishing diet, such as new milk ; 
milk with arrow-root ; strong soups thickened with vermicelli ; jellies, 
and light farinaceous puddings ; and tripe boiled in milk. The food 
should be taken often, and in very small quantities. Excessive acidity 
may be checked by combining lime-water with the milk, or by the use 
of bicarbonate of soda. Nutritive enemata may be given once or twice 
every day ; and cod-liver oil rubbed into the abdomen. Narcotics and 
sedatives to allay pain ; leeches, anodyne plasters, fomentations, and 
embrocations externally.; and rest. 



OTHER FORMS OF STOMACH DISORDER. 

ATONY OF THE STOMACH — ATONIC DYSPEPSIA. 

Symptoms. — Anorexia and slowness of digestion, with occasional 
severe crampy or spasmodic pain some hours after meals, due to the 
presence of undigested food and its passage through the pylorus. Head- 



506 PYROSIS — FORMATION OF ACID IN THE STOMACH. 






ache, flushing after meals, and other symptoms of dyspepsia are occa- 
sionally associated with this condition. 

Cause. — Defective secretion of gastric fluid. 

Treatment. — Brisk exercise and the avoidance of sedentary occu- 
pations and excessive mental labour and anxiety. A light nutritious 
diet, taken in small quantities and often. The use of salt, mustard, 
pepper, a pill composed of gr. v each of mastic or myrrh and extract 
of rhubarb taken daily half an hour before dinner. Generally a carmi- 
native tonic (Form. 263) may be taken with advantage. In many 
cases the mineral acids are of much service (Form. 137). Small doses 
of ipecacuanha often do much good. 

PYROSIS — WATER-BRASH. 

Symptoms. — In the morning or forenoon, when the stomach is 
empty, or some hours after a meal, pain and tension at the pit of 
the stomach, lasting some time, and followed by vomiting of a thin 
w^atery fluid, in considerable quantity, sometimes acid, but often 
insipid. The free discharge of this fluid generally relieves the pain, 
and puts an end to the attack. It may occur only occasionally, or 
last, with intermission, for years. The fluid, which may vary from an 
ounce to a pint or more, is rejected by a sort of rumination and not by 
vomiting ordinary. 

Causes. — P indisposing. Middle age. The female sex. — Exciting. 
Keflex irritation of the abdominal and pelvic viscera, especially the 
uterus. Hence pyrosis frequently accompanies pregnancy. A poor 
diet. 

Treatment. — Improve the diet, and avoid an undue proportion of 
farinaceous substances. If the liquor ejected from the stomach be 
highly acid, alkalies (Form. 138, 166, or 282). Bismuth (Form. 85) 
is a very useful remedy. In other cases the vegetable astringents in 
combination with opium, such as gr. x pulvis kino compositi, are of 
much service. 

EXCESSIVE FORMATION OF LACTIC ACID IN THE STOMACH. 

Symptoms and Treatment. — " This disorder is most common in 
nervous persons with feeble digestion, in whom it not unfrequently 
happens that acid collects in great quantities after meals. They often 
familiarly tell us that almost everything they eat turns to an acid." 
(Budd.) Severe heartburn comes on soon after eating, and is occa- 
sionally relieved after two or three hours by vomiting of very 
sour fluid, the acidity being due to lactic, acid produced by conver- 
sion of the starchy constituents of food into that compound. The 
alkalies afford temporary relief; and the mineral acids more lasting 
benefit. 




( 507 ) 

FORMATION OF ACETIC ACID BY FERMENTATION OF THE 
SACCHARINE CONSTITUENTS OF THE FOOD. 

Symptoms and Treatment. — Heartburn (pain in the stomach and 
sour eructations) after meals ; belching ; and eventually vomiting of 
sour frothy fluid containing much acetic acid with or without a little 
alcohol, are the symptoms of this disorder. Very frequently it is 
associated with the development of the peculiar vegetable organisms 
which have been called by j\lr. Goodsir Sar~ 
cince ventriculi (Fig. 70). The sarcinse are 
found in a brownish scum on the surface of 
the vomited matters. They are often asso- 
ciated with the common yeast fungus, Torula 
cerevisia (Fig. 25, p. 133). 

This foim of stomach disease is often very 
obstinate, and may continue, with greater or 
less severity, for years. Alkalies only give 
temporary relief. The fermentative process may be prevented by 
kreasote given in ii or iii XX\ doses in the form of pill, thrice a day. 
Sulphurous acid is still more effectual ; it may be given in 3ss doses 
diluted with a little peppermint- water twice or thrice a day. 

SYMPATHETIC VOMITING. 

Causes. — Sympathetic disorder of the stomach resulting in vomiting 
may be produced by irritation of the brain, of the lungs, liver, intes- 
tines, kidneys, and ureters, uterus and ovaries. Cerebral and uterine 
irritation are most prone to induce it, as is w T ell illustrated in cerebral 
concussion and in pregnancy. 

When the irritation is prolonged reflex vomiting may become a 
constant and distressing symptom. This frequently happens in the 
latter stage of tubercular disease of the lungs ; constant irritation 
reflected on the stomach leading to the secretion of much sour fluid. 

The treatment must of course be directed to the removal of the 
source of the irritation. In the vomiting associated w T ith phthisis, the 
alkalies and subnitrate of bismuth, combined with hydrocyanic acid 
and the vegetable astringents, are of much service. In other cases, 
such as the passage of a gall-stone, huge doses of opium, in the solid 
form, may be requiied. 



( 508 ) 



DISEASES OF THE INTESTINES. 



Enteritis . 

Dy/SENTERIA 

DlARRHCEA . 

Mel^ena 

Torpor Intestinorum . 

Obstructio Intestinorum 

Intus-susceptio 

COLICA 

Colic a Pictonum . 
Tympanites 
Kemorrhoides . . . 



Inflammation of the Intestines. 

Dysentery. 

Looseness of the Bowels. 

Haemorrhage from the Bowels. 

Constipation. 

Obstruction of the Bowels. 

Invagination of the Bowels. 

Colic. 

Painters' Colic. 

Drum Belly. 

Piles. 






ENTERITIS. 
Definition. — Inflammation of the mucous membrane of the small 



intestine. 



1. GENERAL ENTERITIS. 



Synonyms. — Enteria. Enteritis erythemoidea. Diarrhoea mucosa, 
or catarrhosa. 

Symptoms. — At first chilliness or slight rigor; nausea, and if the 
duodenum be especially affected, vomiting ; thirst ; a white furred 
tongue, with prominent papillae, and a red tip ; heat and soreness in 
the belly, but chiefly about the epigastrium and umbilicus; a dull 
diffused pain on pressure ; and frequent diarrhoea. The nature of the 
evacuations depend on the cause of irritation. They are always fluid : 
at first they contain much undigested matter ; subsequently they are 
chiefly composed of watery mucus, occasionally streaked with blood. 
After the diarrhoea has continued for some hours, the intestine is 
liable to become distended with flatus, producing gurgling and 
griping pain. 

There is anorexia : and if much fluid, or a small portion of solid 
food be taken, it either induces vomiting, or, after a time, produces 
griping pain and increased diarrhoea. Unless the patient be subjected 
to judicious treatment, these symptoms may continue for several days, 
or even for weeks, and his health becomes much impaired. 

Causes. — Imperfect stomach digestion ; the passage of vitiated or 
imperfectly formed chyme into the intestine. A vitiated condition of 
the bile. Drastic purgatives: — the symptoms of enteritis may be well 
studied in the effects produced by a large dose of jalap. Mineral 
poisons, such as arsenic, antimony, and corrosive sublimate. Exposure 
to external cold, causing congestion of the internal organs. 

Treatment. — Warmth to the external surface ; rest, functional 
and mechanical, of the inflamed part, by quietude of body, light diet 
such as may be digested in the stomach, or, if passed into the intestine, 



PARTIAL ENTEEITIS — DYSENTERY. 509 

cannot irritate the inflamed surface. Eggs, milk, beef-tea, arrowroot, 
constitute such articles of diet. Milk, arrowroot, mixed, if depression 
require it, with a little brandy, is generally the most appropriate food. 
The inflammation and its most prominent symptom, diarrhoea, will be 
relieved by Form. 85, 165, 175. Hot fomentations, or stimulant poul- 
tices, may be simultaneously applied to the abdomen. If the diarrhoea 
persist, and the evacuations be bloody, it will be necessary to administer 
mineral astringents (Form. 151, 176). 

2. PARTIAL ENTERITIS. 

Partial enteritis is caused by specific inflammation of the glands of 
the small intestine. The solitary and agminated glands are invariably 
affected in enteric fever ; the attendant symptoms are recorded at 
page 298. They also frequently become the seat of tubercular deposit, 
inducing local inflammation and subsequent ulceration. The symptoms 
of tubercular ulceration of the small intestine, generally speaking, are 
those of well-marked ulceration in enteric fever, viz., persistent purging, 
light-coloured watery stools, griping pain in the abdomen, gurgling 
and tenderness about the right iliac fossa. In both diseases haemorrhage 
to an alarming extent is liable to occur. The general treatment is in 
both diseases alike. Bismuth is very serviceable in the diarrhoea of 
phthisis (Form. 85). 

Morbid Anatomy. — Of the ulceration of enteric fever (see page 
298). Of tubercular ulceration of the intestine: — Large patches of 
ulceration throughout the ileum, separated by intervals of four or six 
inches, commencing as small round discrete ulcers at the upper part of 
the canal, gradually becoming confluent below into large irregular 
patches, extending round the whole circumference of the canal. From 
a description of a single ulcer the appearance of all may be inferred. 
Ulcer irregularly circular, limited by a thick and elevated rounded 
angry-looking border ; within, the margin is irregular and continuous, 
with coarse angry-looking more or less discrete granulations, between 
which little yellow masses of tubercular deposit, firmly attached to the 
base of the ulcer, are here and there seen ; the contiguous parts of the 
intestinal wall much thickened, so that on spreading the ulcerated 
bowel on a flat surface, the patches form considerable elevations. 
Some of the ulcers extend quite down to the peritoneal coat. Their 
position is known before opening the intestine by corresponding vascu- 
larity of the peritoneum, and a feeling of irregular thickening. 



DYSENTERIA— COLITIS— DYSENTERY— BLOODY FLUX. 

Definition. — A specific inflammation of the mucous membrane of 
the colon, accompanied by tenesmus, and mucous, bloody, or purulent 
stools. 

Symptoms. — At first cold shiverings, followed by fever ; or bilious 



510 DYSENTERIA. 

diarrhoea, which, after continuing for a few days, without causing 
much pain or uneasiness, becomes an incessant flux, with discharge of 
pure blood, of mucus, or of a white glairy matter, like white of egg, 
mixed with blood. Masses of indurated faeces often form part of the 
discharges. At the same time, there are severe griping pains in the 
abdomen ; frequent inclination to go to stool ; tenesmus ; dysuria ; and 
cramps in the thighs. The patient is restless, sleepless, and anxious. 
The pulse is quick and hard, the tongue clean, the skin warm and 
moist, the face flushed, and the eye bright. 

In this, the first stage of dysentery, the disease sometimes proves 
fatal by collapse ; but it more commonly assumes the chronic form, 
the purging becomes persistent, pus and blood appear in variable 
quantity in the stools, which are semifluid and pultaceous, mixed with 
shreds of lymph, and excessively offensive. 

Under appropriate treatment the blood and pus disappear, the 
motions look more healthy, the diarrhoea decreases, and after some 
months the patient recovers. But recovery is in many cases very 
much protracted, and in many more it is incomplete, and the purging 
sets in again and again on exposure to cold, or after improper food. 
The patient preserves a good appetite, and does not lose flesh ; but if, as 
is sometimes the case, the disease involve the ileum also, emaciation, in 
proportion to the extent of the disease, results. 

Complications. — The disease may accompany, precede, or follow 
ague, or remittent fever ; and may be complicated with inflammation 
of the liver, spleen, or pancreas. 

Terminations, — In incessant vomiting ; in aphthous inflammation 
of the mouth ; in abscess of the liver ; in ascites ; in fatal haemorrhage ; 
in perforation of the intestine ; in gangrene ; in collapse. 

Morbid Anatomy. — In the acute stage, the mucous membrane of 
the colon inflamed in patches of a deep- red colour, or throughout its 
whole extent; sometimes black, as if gangrenous; sometimes softened. 
The intestine itself contracted. The follicles enlarged and transparent, 
or hard and opaque. In the advanced stage of the disease, ulcers, 
which commence, in the first instance, in the solitary glands, and 
thence spread into small round ulcers, and subsequently (becoming 
confluent) into large ragged patches. The neighbouring tissues are 
much thickened. In some cases, similar appearances in the lower part 
of the small intestines, and occasionally even in the stomach. The 
mesenteric glands often red, swollen, and soft. The intestines, in the 
early stage, contain mucus, blood, and a watery lymph; in the ad- 
vanced stages, pus mixed with blood. 

In cases of long-standing disease the ulcers are found contracted and 
surrounded by tissue of almost cartilaginous hardness. Tough cica- 
trices mark the position of ulcers which have ultimately healed. 

A large majority of the fatal cases of dysentery present abscess in 
the liver. The purulent deposits in this organ may be due to con- 
comitant hepatitis, or (as Dr. Budd has suggested) the pus may be 
derived from the ulcerated intestine (see Pyaemia). 



DYSENTERY. 511 

Causes, — Predisposing, A high temperature. Unwholesome food, 
especially salt meat and unripe fruit ; fatigue, privation, and exposure. 
Intemperance. — Exciting, Marsh miasma ; impure water ; exposure 
to wet and cold, especially at night after a hot day. A debauch. 

DrjRATiON s — From a few days to several weeks, months, or years. 

Mortality. — In acute dysentery from 1 in 8 to 1 in 50 ; in chronic 
dysentery, from 1 in 4 to 1 in 6. 

Diagnosis. — From inflammation and ulceration of the small in- 
testines; by the absence of anorexia, vomiting, and emaciation. From 
ordinary diarrhoea by the presence of sloughy membrane and pus, and 
by the persistence of the purging. 

Prognosis. — Favourable. Moderate diarrhoea, and the absence of 
hectic. 

Unfavourable. — Violent and distressing tenesmus and tormina ; 
vomiting ; hiccup ; cold extremities ; cold and partial sweats ; the 
tongue preternaturally red and dry ; great prostration ; the motions 
extremely foetid ; petechias ; involuntary evacuations ; intermitting 
pulse; complications with diseases of the liver, and intermittent or 
remittent fevers. 

Treatment. — In the acute stage. The hot bath ; leeches to the 
anus or to the tender spots of the abdomen, followed by hot fomenta- 
tions, turpentine stupes, or mustard poultices. Opium in the solid 
form, or Dover's powder, combined with small doses of calomel, blue 
pill, or hydrarg. c creta (Form. 329), every one, two, or three hours, 
according to the severity of the symptoms, and followed at intervals by 
an ounce of castor-oil. Opiate enemata or suppositoria. The strength 
should be supported by light preparations of barley, rice, sago, arrow- 
root, flour, panada, and gelatinous broth; solid food being proscribed. 

Local blood-letting is rarely required in this country ; a full dose of 
castor-oil, with ten or twenty drops of laudanum, and a regulated diet, 
being generally sufficient. 

As the evidence bearing on the treatment of dysentery is very con- 
flicting, it will be allowable to prescribe a treatment founded on the 
nature of the disease. The first object to be accomplished is the re- 
moval of the solid contents of the bowels by full and free doses of 
castor-oil combined with from TY\, xx-xxx of tincturaa opii. Two or 
three such doses might be given with advantage, on successive morn- 
ings. At the same time a diet should be prescribed free from solid 
ingredients, but more or less nourishing according to the state of the 
patient, with an allowance of port wine in cases of great debility* 
Tender spots in the abdomen should be treated with a few leeches, 
followed by warm fomentations : and tenesmus and dysuria by suppo- 
sitories of the compound soap-pill, or small injections of gruel, contain- 
ing laudanum. From the favourable effect of nitrate of potash in 
doses of ten grains frequently repeated in a very troublesome and in- 
tractable form of diarrhoea, I should be disposed to recommend ten 



512 DIABEHCEA. 

grains of this salt with a grain of opium and a grain of ipecacuanha 
three or four times a day. (G.) 

Chronic dysentery is one of the most intractable of diseases ; a fact 
explained by the pathological condition of the diseased intestine. 
Alterations in the calibre of the intestine and the passage of undigested 
food, or of irritating fluids, are sufficient to prevent the ulcers from 
healing. The diet must therefore consist of bread, eggs, and milk ; 
and such other food as will leave no indigestible residue. Vegetables 
must be strictly prohibited. 

The diarrhoea will only yield to the mineral astringents, of which 
sulphate of copper, in J grain doses combined with \ of powdered 
opium, is the most effectual. 

The bowels should be washed out every day with a cold-water 
clyster. 

Prophylaxis. — "Warm and dry clothing ; cleanliness ; a mixed and 
wholesome diet ; avoidance of exposure to wet, cold, and fatigue ; 
prompt change of wet clothing. In the case of armies, a frequent 
change of the site of the camp. 

Remedies. — Emetics; ipecacuanha in small and repeated doses; 
large doses of opium (xx grs. in twenty-four hours) ; acetate of lead 
with opium ; injections of iced water, turpentine ; quinine ; salicine 
''in five-grain doses'; ; decoction of cusparia, combined with nitric acid 
and laudanum ; stiychnia. In chronic cases, injections of nitrate of 
silver, sulphate of copper, or acetate of lead. 



DIARRHOEA— LOOSENESS, OR PURGING. 

Definition. — Frequent discharges of semi-solid, or fluid stools, 
with more or less gastro-intestinal irritation. 

Varieties. — 1. Intestinal dyspepsia. 2. Bilious diarrhoea. 3. 
Mucous diarrhoea. 4. Serous diarrhoea. 5. Diarrhoea with fibrinous 
exsudation. 6. Sympathetic diarrhoea. 

The first form is very common in the autumn and latter part of 
summer. It is produced by the ingestion of fruits. In this country, 
green peas and cucumbers are the most frequent cause of diarrhoea. 
The treatment consists in the removal of the offending matter by a full 
dose of castor-oil, combined, if there be much griping, with TT\x or xv 
of tincture of opium. 

Bilious diarrhoea is very common in the European inhabitants of 
tropical climates. It is caused by use of a larger quantity of animal 
food than is required in hot climates, under which circumstances the 
diminished respiratory function is compensated by the elimination of 
the hydro-carbonaceous constituents of the bile in excessive quantities. 
(See Biliary Congestion.) The secretion is rapidly poured out into 
the duodenum, and sets up bilious diarrhoea. 

The treatment consists: — 1. In relieving the distended condition of 






HELENA. 513 

the liver, by allowing the diarrhoea to continue unchecked for a time. 
If there be pain, gr. xv-xx of bicarbonate of soda may be given in 
combination with TT\v-x of tincture of opium. — 2. By adapting the 
diet to the altered conditions of existence, and substituting vegetable 
for animal food, and avoiding the use of spirituous liquors. 

Mucous diarrhoea, or intestinal catarrh, is a common variety. It 
sometimes co-exists with, and sometimes follows upon catarrh of the 
bronchial mucous membrane. The slightest exposure to cold and damp 
will induce it in many delicate people. It is this form of diarrhoea 
which accompanies enteritis and the acute stage of dysentery. 

The appropriate remedies are sulphuric acid, and the vegetable astrin- 
gents, such as catechu and gallic acid, together with the general treat- 
ment recommended in enteritis. 

Serous or watery diarrhoea often occurs spontaneously in ascites and 
general dropsy, in which conditions it appears to be a natural curative 
process, caused by the direct exsudation of the watery constituents of the 
blood from the congested membrane. It should therefore be encouraged, 
and only controlled when excessive by the vegetable astringents. This 
form of diarrhoea follows the administration of the hydragogue purga- 
tives. Sometimes it alternates with profuse perspiration, as in colliqua- 
tive diarrhoea. In Asiatic cholera it occurs to an intense degree. 

Fibrinous diarrhcea is very rare. The discharges, in the form of 
shreds or tubular membranes, resemble those of croup, or of plastic 
bronchitis. In the treatment the astringent mineral salts are very 
serviceable. 

Sympathetic diarrhoea. — In place of morning sickness, many women 
experience diarrhoea during the early months of pregnancy. It frequently 
occurs in children during teething ; emotional excitement quickly in- 
duces it in persons of the nervous temperament. It readily yields to 
small doses of opium. 

From the foregoing it appears that there is no single treatment for 
diarrhoea. Before prescribing remedies w^e ought, from the previous 
history, or from the nature of the evacuations, to determine the precise 
cause. 

Causes. — Cold applied to the surface; suppressed perspiration; 
mental emotions ; pregnancy ; teething ; the heat of the summer and 
autumn seasons ; indigestible food ; unripe fruits, or ripe fruits in 
excess ; putrid substances ; the abuse of active purgatives ; previous 
constipation ; worms ; retrocedent gout or rheumatism ; phthisis : 
enteric fever. Diarrhoea is a frequent precursor of Asiatic cholera. 



MELfiNA— HEMORRHAGE FROM THE BOWELS. 

Definition. — The discharge of dark-coloured, or more or less altered, 
blood from the bowels. 

Causes. — Melsena is symptomatic 01 diseases of the liver, heart, and 

2 L 



514 CONSTIPATION OBSTRUCTION. 

lungs, obstructing the general venous and portal circulations (see 
Haematemesis, page 498) ; ulcer of the stomach, or duodenum ; tuber- 
cular ulceration of the small intestine ; enteric fever ; dysentery ; 
intussusception ; ruptuie of an aneurismal sac into the bowel. 

Diagnosis. — From haemorrhoids by the darker colour and larger 
quantity of the blood, and by the absence of soreness and tenesmus. 

Treatment. — That of the condition producing it. (See the several 
diseases above enumerated.) 



TORPOR INTESTINORUM— CONSTIPATION. 

The causes of constipation are either structural or functional. 

The structural causes either narrow the intestines or obliterate the 
passage. In the one case, purgative medicines act with difficulty ; in 
the other case, action of the bowels is impossible. 

Among the functional causes of constipation, are the absence of irri- 
tating matter from the diet, a deficiency of bile, want of proper exercise, 
spasmodic action or paralysis of some part of the gut. 

The treatment of constipation, due to alteration of function, will 
depend on the character of that alteration. If the food be deficient in 
indigestible matter, we must supply it by brown bread or ripe fruits ; 
if the bile be wanting, we must stimulate the secretions of the liver by 
mercurial preparations in small doses ; if the habits be sedentary, we 
must enjoin proper exercise. The other functional disorders will be 
noticed under the head of Colic. 

Habitual constipation is best treated by rhubarb in powder or infu- 
sion (Form. 263, 282). When the torpor of the bowels is still greater, 
and especially where there is a large accumulation of hardened faeces, 
purgative enemata are required (see Formulae 291) ; aided by castor- 
oil by the mouth. 

A stream of cold water poured from a height on the abdomen has 
sometimes relieved obstinate constipation. Electricity is serviceable in 
some cases, one of the conductors being inserted within the rectum. 



OBSTRUCTION OF THE BOWELS. 

It sometimes happens that all our remedies fail to relieve the bowels. 
If in such a case there be tenderness in any particular part of the abdo- 
men, accompanied by vomiting, we may be sure that there is obstruc- 
tion, more or less complete, to the pas>age of faecal matter, and it 
becomes a matter of the most urgent necessity to ascertain the cause 
and situation of the obstruction. The causes are: — 

1. Strangulation or incarceration of a portion of intestine: a small 
knuckle of intestine may, after careful examination, be found at the 



INVAGINATION. 515 

femoral opening, or in the scrotum or labium, and no other symptom of 
hernia but constipation be present. The strangulation may be internal, 
and caused either by intussusception, or by the entanglement of a 
portion of intestine in a band of the mesentery or in some old adhesion. 

2. Faecal accumulations, forming large, hard, dry masses, filling up 
the cells of the colon, are liable to form round biliary calculi, cherry 
and plum stones, and other foreign bodies. These accumulations feel 
like hard, irregular tumours, and may be mistaken for adventitious 
growths. Faecal accumulations are very apt to form in the caecum, 
where they often set up violent inflammation, with symptoms of com- 
plete obstruction. If the inflammatory symptoms be not subdued, 
pelvic abscess and perforation are very liable to result. The inflamed 
caecum sometimes becomes adherent to the anterior abdominal wall, an 
abscess forms and points, and at length pus and faecal matter discharges 
through an opening communicating with the interior of the intestine. 

3. Cancerous growths, chiefly of the rectum ; and cicatrized ulcers 
of the bowel, are other causes of obstiuction. 

Treatment. — Reduce the hernia, and give a copious clyster of gruel. 
If the strangulation be internal, and the symptoms urgent, a careful 
diagnosis of the exact seat of strangulation should be made ; the abdo- 
men should be opened without delay, and the bowel disengaged. If the 
obstruction be due to accumulation in the caecum and large intestines, 
large castor-oil or soap enemata should be thrown up, and hot fomenta- 
tions simultaneously applied to the abdomen. If there be symptoms of 
inflammation, leeches must be freely applied over the inflamed part. 
The vomiting may be allayed by iced soda-water, and the pain by large 
doses of opium. When the scybala reach the rectum, it may be necessary 
to assist their discharge by a forceps or scoop, In cases of unrelieved 
obstruction, perforation is iiable to occur. 

The symptoms and treatment of Perforation of the Intes- 
tines are the same as those of the stomach. (See page 504.) 



INTUS-SUSCEPTIO-— INVAGINATION. 

Symptoms. — During the violent action of strong purgatives, or after 
severe colic, a constant desire to go to stool, violent tormina and tenes- 
mus, discharge of blood, or of scanty bloody mucus, and the symptoms 
of enteritis. These symptoms are not decisive, but the existence of 
the disease becomes more probable after the failure of attempts to 
evacuate the bowels, and the supervention of hiccup and stercoraceous 
vomiting. 

Morbid Anatomy. — One portion (from a few lines to more than a 
foot in length) of the intestines enclosed within another. In most cases 
there is only one of these invaginations, but in some instances there are 
several. The most common seat of the obstruction is the junction of 



516 COLICA. 

the small and large intestines ; but it may take place in any part of 
the small intestines, and in the arch of the colon. A natural cure is 
sometimes effected by adhesion, suppuration, gangrene, and separation 
of the enclosed portion of intestine, the presence of which may be looked 
for in the stools. 

Diagnosis. — Sudden obstruction of the bowels, followed by a percep- 
tible tumour in the abdomen, and the passage of blood, would give 
reason for suspecting the existence of this disease. The discovery of a 
portion of the intestinal tube in the stools would furnish conclusive 
evidence. 

Prognosis. — Very unfavourable. In a few cases recovery takes place 
after sloughing of the constricted portion of intestine. 

Treatment. — I. If there be marked tenderness in any part of the 
abdomen, leeches must be applied to the spot, followed by warm poul- 
tices, or hot fomentations. 

II. The distressing vomiting is best relieved by iced soda-water. 
Solid opium, or its tincture, should also be given at short intervals, so 
as to moderate the pain and control the disordered peristaltic action. 

III. To relieve the obstruction, a large quantity of warm water 
should be thrown up into the bowels by the long elastic tube ; if this 
should fail, air may be injected. This treatment may be repeated at 
intervals, till the bowels are relieved, or till such attempts at relief 
seem hopeless. After the failure of all these attempts, the mechanical 
remedies recommended for removing the obstruction may be resorted 
to ; or the sac of the peritoneum may be opened, and the intestine 
unravelled. 



COLICA— COLIC. 



Definition. — Painful contraction and disordered peristaltic action 
of the intestines, from the presence of hard faeces or air in the 

intestines. 

Symptoms. — Severe twisting pain in the abdomen, occurring in 
paroxysms, with retraction of the umbilicus and troublesome flatulence. 
The pain is relieved by pressure ; the pulse is little, if at all, increased 
in frequency. 

Causes. — The presence of undigested hard substances, such as unripe 
fruit and uncooked vegetables in the intestines ; hardened faeces (scybala ), 
or other accumulations ; flatulent distension ; obstruction of some part 
of the intestinal canal from impacted faeces ; stricture, or strangulation : 
worms ; certain metallic poisons ; e.g., lead. 

Diagnosis. — From peritonitis, by the peculiar twisting pain and 
retraction of the navel ; by the absence of fever ; and by the pain being 
alleviated by pressure. 

Rheumatism of the abdominal muscles is distinguished at page 356. 



LEAD COLIC. 517 

Treatment. — Having ascertained that there is no concomitant in- 
flammation, and no mechanical obstruction detectable, and, at the same 
time, that the pain is not merely muscular — the bowels, if there have 
been defective action, should be freely relieved by a full dose of castor- 
oil with TT^x to TY\xv of tincture, of opium. 

If the colic be due merely to flatulent distension give 3J spiritus 
chloroformi, with Jss tincturae rhei co., and TY\ x tincturae opii. 

If there be symptoms of obstruction, we must avoid active purgatives, 
and trust to enemata. A large clyster of thin gruel containing a 
drachm of the tincture of opium may be thrown up, either by means of 
the common clyster-pipe or through the flexible tube. Should the 
bowels continue unrelieved, and there are still no symptoms of inflam- 
mation, the patient should be kept under the influence of opium till a 
free evacuation takes place. Meanwhile, the pain may be relieved by 
applying flannels wrung out of hot water or the poppy fomentation ; 
or by steady pressure. 

It is not unusual in cases of colic to find, on inquiry, that one of the 
first symptoms was the discharge of a quantity of gelatinous mucus 
from the bowels. In such cases there is commonly more or less tender- 
ness in some part of the abdomen, especially in the right iliac fossa, and 
from six to twelve leeches, followed by a warm bread-and-water poultice, 
should be applied to the tender spot. (G.) 

Flatulence may be relieved by the introduction of the long flexible 
tube, which may also be used to convey warm water into the gut. 

In spite of the persevering employment of these means, six or seven 
days will sometimes elapse before the bow T els can be made to act. 



COLICA PICTONUM— LEAD COLIC. 

Synonyms. — Colic of Poictou. Painters' colic. Devonshire colic. 

Symptoms. — Those of colic from other causes, the pain generally 
coming on more gradually, and being often accompanied with pains in 
the limbs, or with weakness, or complete paralysis of the hands or fore- 
arms. The abdomen is generally retracted. 

Diagnosis. — From common colic, by the history of the case and the 
employment of the patient ; and generally by the blue line along the 
margin of the gums indicating the action of lead on the system. 

Prognosis. — Favourable. Five fatal cases in 500. (Andral.) 

Treatment. — Sulphated aperients (Form. 264) ; enemata of warm 
water ; hot fomentations or the warm bath. 

Prophylaxis. (See Lead Palsy, p. 399.) 



( 518 ) 

TYMPANITES— METEORISMUS— DRUM BELLY. 

Symptoms. — The abdomen distended, tense, elastic, and painful, and 
sounding, on percussion, like a drum. The air is, in almost all cases, 
contained in the stomach and intestines, its most common seat being the 
arch and sigmoid flexure of the colon. In very rare instances air passes 
into the sac of the peritoneum, in consequence of ulceration of the 
bowels. Tympanites is a painful symptom in severe cases of enteric 
fever, and in the latter stages of peritonitis. 

Causes. — Loss of tone in the intestinal canal ; indigestible food ; 
abuse of purgatives ; hysteria. 

Diagnosis. — From ascites, by the clear sound and absence of fluc- 
tuation. 

Treatment. — In mild cases of flatulent distension of the bowels, 
the remedies usually resorted to are essence of ginger with hot water, 
or brandy and water swallowed as hot as it can be readily borne. In 
severe cases large doses of opium with 5J of spirit of chloroform, or iii-v 
drops of cajeput oil may be necessary. If the distension be very great 
it may often be relieved by the passage of a long wide elastic tube into 
the bowel. Stimulant enemata (Form. 72) often give great relief. 

The use of food known to occasion flatulence should be carefully 
avoided. 



rLEMORRHOIDES— THE PILES. 

1. EXTERNAL PILES. 

Definition. — Small round tumours, situated at the verge of the 
anus, aud covered with skin or mucous membrane, or painful folds of 
integument. The tumours either discharge blood, when they are called 
bleeding piles, or they do not bleed, when they are called blind piles. 
When free from pain they are called indolent. 

Symptoms. — When piles are in an inflamed state they occasion heat, 
itching, and pain, with a sense of weight and tension, increased upon 
going to stool, which generally occasions a discharge of blood. The in- 
flammation sometimes runs on to suppuration. In mild cases piles 
appear and disappear, and are often absent for long periods of time. 

2. internal piles. 

Symptoms. — A sensation as of a foreign body in the rectum, with 
frequent desire to relieve the bowels, and painful strainings, accompa- 
nied by discharges of blood. In the more severe cases, dysuria, pain in 
the back and down the thighs, and, in females, uterine irritation. 

Causes. — Luxurious and sedentary habits ; habitual costiveness ; 



ENGLISH CHOLERA, 519 

plethora ; hard riding ; excesses of various kinds ; the suppression of 
some habitual discharge ; the frequent use of strong aloetic purgatives ; 
varicose condition of the hemorrhoidal veins; pregnancy. 

Prognosis. — The discharge of blood by piles is often salutary, espe- 
cially in persons advanced in life, and their suppression may be followed 
by more serious haemorrhage, such as apoplexy. 

Treatment. — I. General. II. Local. 

I. The circulation of blood through the abdominal vessels must be 
promoted, and the regular action of the bowels maintained. To effect 
this, we must enjoin activity and abstemious living. The most suitable 
aperients are those prescribed in Form. 282 and 286, or simply confection 
of senna. 

II. The local treatment consists in the strict observance of cleanliness, 
washing with cold water after each motion, and the careful return of 
the piles, if, being internal, they protrude during the evacuation of 
the bowels ; in the use of astringent washes or ointments (such as the 
liq. plumbi subacetat., the unguentum gallae cum opio). When the 
piles are inflamed, the application of leeches, followed by cooling lotions. 

Bleeding piles also require the use of cold astringent applications and 
injections. Daily injections of cold water are highly beneficial. When 
the haemorrhage is profuse, astringents may be given internally. The 
best is the perchloride of iron. The haemorrhage, when very profuse, 
must be treated by astringent injections of alum and tannic acid. 

Piles, strangulated by the spasm of the sphincter, must be compressed 
with the finger and passed back ; the operation being facilitated by the 
use of the warm bath. A T bandage may become necessary. 

When the tumours become chronic they should be removed. 

Prophylaxis. — Patients affected with piles should sit and ride as 
little as possible, and pursue their avocations , if inactive or literary, in 
an erect posture. 



DISEASES OF THE STOMACH AND INTESTINES. 

Gastro-Enteritis Mucosa . . English Cholera. 
Cholera Maligna .... Malignant Cholera. 

GASTRO-ENTERITIS MUCOSA— ENGLISH CHOLERA. 

Symptoms. — Nausea, pain, and distension of the stomach and intes- 
tines, succeeded by vomiting, and by purging of bilious or foculent 
matter, and, when this has been discharged, of mucus. The tongue is 
furred ; the pulse is frequent, small, and sometimes unequal ; and there 
is much thirst. In rare cases death takes place within the space of 
twenty-four hours, after hiccup, cold sweats, great anxiety, blueness of 
the surface, and painful cramps of the extremities. 

Causes. — Excessive heat, or sudden transitions from heat to cold ; 
the summer and autumnal seasons ; indigestible food ; unripe fruit, or 



520 r CHOLEKA MALIGNA. 

an excessive quantity of ripe fruit ; putrid meat ; decayed vegetables ; 
violent purgatives ; irritant poisons ; catarrh. 

Diagnosis. — From enteritis by the co-existence of gastric symptoms. 
The disease in its most severe form is not distinguishable from Asiatic 
cholera. 

Prognosis. — Favourable. Cessation of the vomiting, tendency to 
sleep, warmth and moisture of the skin. The disease, when protracted 
to the third or fourth day, seldom proves fatal. — Unfavourable. Pain- 
ful cramps of the extremities ; convulsions ; great prostration ; cold, 
clammy sweats ; anxiety ; short hurried respiration ; continual hiccup ; 
intermitting pulse. 

Treatment. — A farinaceous diet, and the entire exclusion of solid 
food. A scruple of the compound chalk and opium powder, or a mucila- 
ginous mixture, with twenty drops of tincture of hyoscyamus, may be 
given three or four times a day. When there is great prostration of 
strength, full doses of opium, with stimulants, are indicated, with 
warmth to the surface, and mustard sinapisms to the extremities. 

When the disease has subsided, the usual diet must be gradually 
resumed, and tonic medicines given if there be much debility. 



CHOLERA MALIGNA— MALIGNANT CHOLERA. 

Synonyms. — Cholera morbus ; epidemic, spasmodic, Indian, Asiatic, 
blue, and pestilential cholera. Cholerine — a diminutive term. Cholera 
asphyxia — a term indicative of the state of collapse in fatal cases. 

Definition. — An epidemic malady due to impure food and water, 
characterised by profuse vomiting and purging with symptoms of col- 
lapse allied to asphyxia. 

Symptoms. — In a few cases (rarely seen out of India), the attack is 
sudden ; the patient vomits once or twice, or passes one or two loose 
motions, complains of giddiness, blindness, or deafness, falls down, and 
expires in a few minutes. In another and larger class of cases the 
disease shows itself after two or three days of slight indisposition, with 
depression of spirits, loss of appetite, oppression at the praecordia, 
rumbling in the bowels, giddiness, noises in the ears, and twitchings in 
the limbs. In a still larger class the fully-formed disease sets in after 
a preliminary attack of diarrhoea of some hours' or days' continuance. 

In the majority of cases, both in India and in England, the following 
is the order of the symptoms: after a preliminary attack of diarrhoea, 
of greater or less severity, and lasting for some hours or days, the 
patient is seized with symptoms of collapse, accompanied, in most cases, 
by vomiting. The acts of vomiting and purging are generally un- 
attended by pain or tenderness in the abdomen ; and the matters 
rejected from the stomach and bowels are free from bile and colourless, 
have a faint fishy smell, and resemble yeast ; or they consist of a thin 



MALIGNANT CHOLEKA. 521 

colourless serum, or bear a close resemblance to rice-water, being 
familiarly known as " rice-water evacuations." Sometimes they have 
a pink colour, or the deeper hue of port wine. Severe and painful 
cramps commence in the fingers and toes, and rapidly extend to the 
calves of the legs, to the thighs, and muscles of the abdomen; the 
eyes are sunk, and surrounded by a dark circle ; the features contracted 
and sharpened ; the expression of countenance indifferent and apathetic ; 
the face, extremities, and sometimes the whole surface of the body, 
assume a leaden, bluish, or purple hue ; the limbs are shrunken and 
contracted ; the nails blue ; the hands clammy and sodden ; the surface 
covered with a profuse cold sweat; the pulse thready or imperceptible 
at the wrist, arm, axilla, temple, and neck ; and if a vein or artery be 
opened, the blood trickles away, thick and dark. In spite of the 
extreme coldness of the surface, the patient complains of heat, throws 
off the bedclothes, and suffers from great restlessness and incessant 
jactitation, complains of a burning heat in the epigastrium, and is 
tormented with thirst ; the respirations are below the number in 
health, the inspiration difficult, and the expiration short and con- 
vulsive ; the voice is plaintive, the patient speaking in a hoarse 
whisper ; the breath feels cold ; the tongue is white, or of a leaden 
colour, cold and flabby; the temperature often as low as 79° or 77°, 
and even 72°. The secretion of urine is partially or entirely sup- 
pressed, and the body exhales an earthy or cadaverous odour. In this 
state of collapse the disease often proves fatal, the patient dying without 
a struggle, and retaining his faculties - to the last. In other cases he 
gradually rallies, the pulse rises, the blueness of the surface disappears, 
the body resumes its w x armth, the cramps and vomiting cease, bile 
appears in the motions, the secretion of urine is restored, and a rapid 
and complete recovery takes place. But in a third class of cases the 
improvement is partial and temporary, and the patient falls into the 
typhous condition from which he may possibly recover after several 
days. 

Terminations. — In sudden death ; in death after severe primary 
or secondary symptoms ; in recovery ; in prolonged gastric irritation ; 
in secondary fever, of the typhous character, and often accompanied by 
a rash resembling urticaria febrilis. 

Pathology and Morbid Anatomy. — The disease appears to 
consist in a sudden rejection of the fluid parts of the blood through 
the mucous membrane of the alimentary canal ; the intestines are 
filled with a white flaky liquid ; the mucous membrane is swollen, 
and greatly congested in patches ; all the glands of the intestines are 
large and prominent ; the veins and arteries loaded with dark blood ; 
the lungs congested in some cases, extremely contracted in others ; the 
liver and gall-bladder gorged with bile ; the kidneys congested ; the 
urinary bladder contracted and empty. In patients who survive the 
stage of collapse, and die after the secondary fever, the morbid appear- 
ances are those present in typhus. 

Duration. — In fatal cases, from a few minutes to twelve hours or 



&11 TREATMENT OF CHOLERA. 

more. More than half the fatal cases die within twenty-four, and 
nearly a sixth within six, houis. The average duration is about two 
days. The duration of the cold stage varies from a few minutes to 
forty-eight hours or more, while that of the febrile stage may extend 
frcm four to ten days or more. 

Mortality. — At the onset of the epidemic nine-tenths of the cases; 
on the average about one-half; at the decline a small fraction. Deaths 
from cholera in England and Wales, in 1831-32, 30,924 ; in 1848-49, 
54,398; in 1853-54, 24,516. Deaths in London, in a million of 
inhabitants, 6209 in 1849, and 4269 in 1854. 

Causes. — Predisposing. Debility; impaired health ; intemperance; 
impure air ; impure water ; low and damp situations ; the summer 
and autumn seasons. — Exciting. A peculiar poison contained in water 
arising from the decomposition of animal matter. 

Diagnosis. — From English cholera, by the greater severity of the 
symptoms. The complete suppression of urine, the intense blueness of 
the surface, the hoarse, feeble voice, and the shrunken appearance of 
the countenance, are the diagnostic signs of this disease. But these 
marks will not serve to distinguish the disease from the more severe 
cases of English cholera. The premonitory diarrhcea of cholera is dis- 
tinguished from ordinary diarrhcea by the absence of pain. 

Prognosis. — Favourable in the early stage before collapse has set 
in, and in the secondaiy stage when the febrile symptoms are slight ; 
unfavourable during the stage of collapse, and in the secondary fever 
when it assumes the typhous character. — Favourable Symptoms. Cessa- 
tion of cramp: subsidence of vomiting and purging, and the reappear- 
ance of bile in the motions ; voiding of urine ; return of the pulse ; 
restoration of heat in the extremities and surface of the body ; disap- 
pearance of the blueness of the skin and of the fades hippocratica. — 
Unfavourable Symptoms. Extreme collapse: absence or cessation of 
vomiting and purging in the stage of collapse ; deafness ; the evacua- 
tions of the colour of port wine. Advanced age, previous debility, or 
ill health, and previous habits of intemperance, aie unfavourable cir- 
cumstances, and the disease is somewhat more fatal in females than 
in males. 

Treatment. — I. Of the preliminary diarrhcea. II. Of the stage 
of collapse. III. Of the stage of reaction. 

I. The preliminary diarrhoea requires the treatment of common 
diarrhcea. A scruple of the compound chalk and opium powder may 
be given three or four times a day, the diet being at the same time 
restricted to gruel or arrowroot, made with milk. In more severe 
cases, grain-doses of opium, in combination with J grain of sulphate of 
copper, may be given every hour, or every two or three hours. When 
the patient is in a weak and exhausted state, brandy may be ad- 
ministered from time to time. In epidemics of Asiatic cholera, patients 
suffering from diarrhcea should be promptly treated and carefully 
watched. 



TREATMENT OF CHOLERA. o2S 

H. The stage of collapse is best treated by large draughts of cold 
water, or water holding a little chlorate of potash in solution. The 
most hopeful means of restoring the circulation and of contracting the 
intestinal vessels, is the injection of the g L f a grain of Atropia into 
the arm at intervals of an hour. At the same time reaction should be 
promoted by warm blankets, bottles of hot water to the feet and epigas- 
trium, and assiduous friction. The patient may be allowed to drink 
freely of warm brandy and water. The cramps may be relieved by 
rubbing and the forcible extension of the parts affected. 

III. Reaction having been established, the treatment must be guided 
by the symptoms actually present. The thirst may be assuage 1 by 
large draughts of water : diarrhoea, if it exist, may be met by opium 
in doses of one grain, repeated at short intervals, or by a strong decoc- 
tion of logwood in combination with laudanum and aromatic spirit of 
ammonia ; and the warmth of the skin may be kept up by frictions 
and warm applications. In the absence of diarrhoea, the bowels should 
be relieved by occasional doses of castor-oil. 

If the reaction be excessive, and assume the form of fever, it must 
be treated as enteric fever ; and if it assume the typhous type, by the 
remedies appropriate to that condition. 

Prophylaxis. — Temperate habits; wholesome diet; and pure 
boiled and filtered water ; the moderate use of wholesome vegetables 
and ripe fruits ; the early treatment of diarrhoea. Those who are able 
to do so, should remove from low-lying districts to high grounds. On 
the approach of cholera, the authorities should provide a supply of 
water of ascertained purity, and prevent access to pumps and sources 
liable to contamination. They should organize means for the treatment 
of diarrhoea, and also adopt measures for insuring personal and house- 
hold cleanliness ; for the early removal of all refuse matters ; and for the 
suppression of nuisances. Armies attacked by cholera in low situations 
should be encamped on high ground, and draw their supply of water 
from pure springs or rivulets. 

Remedies. — Castor-oil, in the dose of a table-spoonful repeated at 
short intervals, so as " to produce vomiting and purging sufficient to 
insure, from time to time, the evacuation of the stomach and intestines, 
and to prevent the accumulation of morbid secretions " as practised by 
Dr. George Johnson. Saline medicines. Injections of warm water and 
of warm saline solutions (sodii chloridii, J>s, sodae bicarb., gr. c, aquae 
callidse ox.) into the veins (a mode of treatment followed by the most 
prompt and marked relief to all the symptoms, but not to be com- 
mended as curing cholera) ; transfusion of blood ; calomel, in scruple 
or half-drachm doses* every hour ; cajeput oil ; galvanism ; large doses 
of opiates ; camphor ; acetate of lead in combination with opium. A 
drachm of laudanum and a scruple of calomel administered at the first 
seizure, and repeated at a short interval, if necessary; chloroform; 
chloroform and brandy ; quinine in large doses ; Indian hemp. 



( 524 ) 



DISEASES OF THE PERITONEUM. 

Peritonitis . . Inflammation of the Peritoneum. 
Ascites . . . Dropsy of the Belly. 

PERITONITIS— INFLAMMATION OF THE PERITONEUM. 

Varieties. — 1. Simple. 2. Tubercular. 

1. simple peritonitis. 

Symptoms. — After rigors, but, in some cases, without any prelimi- 
nary symptoms, pain commencing in any part of the abdomen, and 
soon extending over the entire cavity, increased by pressure, and often 
so acute that even the weight of the bed-clothes is intolerable. The 
skin of the abdomen is hot ; the pulse is in general small, hard, and 
contracted, though sometimes full and soft ; the countenance is ex- 
pressive of great suffering ; the patient lies on his back with the thighs 
drawn upwards, and flexed on the abdomen ; the bowels are consti- 
pated ; the urine scanty and high-coloured ; the tongue is white and 
covered with mucus, and soon becomes dry and brown ; the breathing 
is thoracic, short, each inspiration causing an increase of the pain. There 
is frequent gulping, and generally constipation, and some strangury. 
The disease often terminates fatally within twenty-four or forty-eight 
hours. Death occurs by asthenia, and is preceded by great prostration 
of the vital powers, sudden cessation of pain, sharpened countenance, 
distension of the abdomen by liquid or gas, vomiting of a coffee-coloured 
fluid, cold extremities, and stupor. 

Morbid Appearances. — Injection of the vessels of the perito- 
neum ; coagulable lymph spread over the surface, or flakes of lymph 
floating in serum or pus ; the folds of the intestines adherent by 
coagulable lymph to each other and to the contiguous viscera. In 
chronic cases the adhesions are organized, binding the intestines so 
firmly together as to greatly hinder peristaltic movement. 

Causes. — Cold and fatigue ; constipation ; contusions ; wounds, sur- 
gical operations ; parturition ; rupture of any of the abdominal viscera. 

Prognosis. — Favourable, in peritonitis from common and transient 
causes. — Unfavourable, in that produced by mechanical injury, organic 
disease, parturition, or ruptuie of the abdominal viscera. 

Diagnosis. — From rheumatism or neuralgic pains of the abdominal 
muscles, by the pain being increased by pressure, and by the presence 
of severe constitutional symptoms. From colic, by the character of 
the pain. (See p, 516.) In colic the patient writhes about and 
changes his position. In peritonitis even the abdominal respiratory 
movements are avoided. From ovarian inflammation (see Oophoritis). 
From hysterical tenderness and pain, by the severe constitutional 
symptoms. The disease, in its early stage, may be distinguished by 



TUBERCULAR PERITONITIS. 525 

a feeling of crepitation under the hand, and a to-and-fro sound on 
applying the stethoscope while the abdominal parietes are in motion, 
as in the act of inspiration. 

Treatment. — In recent and acute cases bleeding from the arm, fol- 
lowed by leeches and warm fomentations, and the internal use of tartar- 
emetic with calomel and opium in full doses, and at short intervals, 
so as speedily to effect the system. In very severe cases, mercurial 
inunction may be employed at the same time. If the stomach be irri- 
table, the tartar-emetic must be omitted. In less severe cases, leeches 
to the abdomen, followed by warm fomentations, and calomel and 
opium internally. 

The large intestines may be relieved by enemata of warm water or 
warm gruel. 

If there be painful tympanites, turpentine enemata are required, or 
the long elastic tube may be introduced so as to allow the accumulated 
gas to escape. 

When effusion has taken place, and the febrile symptoms have abated, 
the treatment will be that of ascites. 

Chronic peritonitis must be treated by the repeated application of 
leeches, blisters, and stimulant embrocations to the abdomen. If the 
intestines become adherent from organization of the plastic lymph 
thrown out around them, obstinate constipation is the result. The 
intestines being firmly bound together are no longer able to perform 
their peristaltic movements. Such cases require very careful treatment. 
Only such food should be taken as is readily absorbed. The consti- 
pation must be treated by enemata and very mild laxatives, such as 
castor-oil and confection of senna. 

2. TUBERCULAR PERITONITIS. 

Symptoms. — These come on very insidiously. The abdomen slowly 
enlarges until it at last attracts the notice of the patient, and when he 
first comes under treatment ascites to a considerable extent is present. 
The general health now begins to fail ; emaciation, sweating, and 
diarrhoea, alternating with constipation, set in ; the abdomen becomes 
tense, painful, and tender (the pain is at first deep-seated) ; hectic, and 
gastro-intestinal irritation, resulting in vomiting and more severe 
diarrhoea, sooner or later supervene, the food is rejected, and the patient 
dies of asthenia. Sometimes the mesenteric glands and the folds of the 
mesentery are the chief seat of the tubercular deposit, and hard nodular 
tumours may be felt through the abdominal walls, and the chief, and 
it may be, only other symptoms present, are emaciation and swelling of 
the belly. This variety of the disease is called Tubercular mesenteritis 
and Tabes mesenterica. It is only in the latter stages of this variety 
that ascites becomes a prominent symptom. When the tubercular 
matter is deposited simultaneously in the mesenteric and intestinal 
glands and upon the general peritoneal surface, the emaciation is very 
rapid, and the pallor of surface extreme. 



526 ASCITES. 

Morbid Anatomy. — If the disease kills speedily, the peritoneal 
cavity will be found distended with clear serum, and the peritoneal 
covering of the intestines uniformly granular with miliary tubercles 
the size of hemp seeds. The mesenteric glands are more or less en- 
larged and hardened. In the more chronic form the mesenteric glands 
are greatly enlarged, forming hard nodular matted masses. When 
opened the centres of many will be found softened. When persistent 
and intractable diarrhoea has been a prominent symptom, we may expect 
to rind tubercular ulceration of Peyer's glands. (See page 509.) 

Diagnosis. — From ascites, caused by hepatic disease, by the absence 
of jaundice and hepatic enlargement or inequality. From enteric fever 
(see page 301). The disease is often accompanied, sooner or later, by 
symptoms of pulmonary phthisis. 

Treatment. — Iodide of iron alone or combined with cod-liver oil. 
Alternate inflections of cod-liver oil and iodine unguents into the abdo- 
men. Chalybeate tonics. The gastro-intestinal symptoms must be 
treated as directed under Phthisis and Partial Enteritis. 



ASCITES— DROPSY OF THE BELLY. 

Symptoms. — A progressive and uniform enlargement of the abdo- 
men, accompanied, when the quantity of fluid is large, by tension of 
the parietes ; dulness on percussion over the whole abdomen, when the 
fluid is abundant; and when small, over the part to which the position 
of the patient causes it to subside, the rest of the abdomen being tym- 
panitic ; and a sense of fluctuation becoming more distinct as the 
quantity of fluid increases. 

The general symptoms of ascites are due to pressure of the accumu- 
lated fluids, and when it is merely a symptom of some other disease, 
to the particular disease present. The symptoms arising from pressure 
are difficulty of breathing ; suffusion of the countenance, and injection 
of the eyes ; and distension of the superficial veins of the abdomen. 
Thirst, a dry skin, scanty urine, and torpid bowels, are among the 
most common accompaniments of ascites. 

The disease seldom continues long without inducing, or being accom- 
panied by an anasarcous state of the lower extremities. 

Causes. — The general causes of dropsy (see Hydrops). Disease of 
any organ obstructing the portal circulation. Ascites, therefore, is the 
immediate consequence of obstructive diseases of the liver, and of 
cirrhosis in particular ; cancel ous disease of the pancreas, involving the 
portal vein, is an occasional cause. Diseases of the spleen and mesen- 
teric glands ; of the heart, lungs, and kidney ; scarlatina ; loss of tone 
in the peritoneum after pregnancy; chronic or sub-acute inflammation 
of the peritoneum ; and local injury, or other causes of ascites. 

Diagnosis. — From ovarian dropsy, by the uniform enlargement 



DISEASES OF THE LIVER — CONGESTION. 527 

and greater width of the abdomen, which sways from side to side 
according to the position of the patient. From tympanites, by the 
dulness on percussion over the seat of the fluid, or over the greater part 
of the abdomen. When the intestines are distended with air they float 
on the surface of the fluid, giving a tympanitic resonance to the upper 
parts of the abdomen. The pregnant uterus forms a defined rounded 
tumour, which contracts under the hand ; moreover, we may feel the 
foetal movements, and hear the pulsations of the foetal heart. A dis- 
tended bladder causes a uniform pyriform enlargement above the pubes, 
and is associated with constant dribbling of urine. 

Prognosis. — Favourable. The ascertained absence of organic disease 
of the viscera of the chest and abdomen. The urine healthy, in quality 
and quantity, and not coagulating by heat ; moist skin ; the swelling of 
the abdomen diminishing ; the respiration becoming free ; the strength 
little impaired. — Unfavourable. Organic disease of the viscera of the 
chest and abdomen, especially of the liver ; great emaciation ; sympa- 
thetic fever; coma; an impaired constitution. 

Treatment. — If pain and tenderness exist, leeches to the abdomen, 
followed by mercury so as to affect the mouth. If both are absent, the 
treatment must vary with the disease, of which the ascites is the effect. 
If disease of the liver, heart, lungs, or kidney be present, the remedies 
appropriate to that disease. The remedies for the dropsy itself, irre- 
spective of the causes which may have produced it, are diuretics, and 
drastic purgatives, unless contra-indicated. The choice of diuretics must 
be partly determined by the cause of the dropsy, and partly by the 
existing state of the patient. 

If, after a fair trial, these remedies are unavailing, and the pressure 
becomes insupportable, recourse must be had to tapping. 

Ascites is often combined with anasarca. 



DISEASES OF THE LIVER. 

Congestio Congestion of the Liver. 

Hepatitis Inflammation of the Liver. 

Abscess Of the Liver. 

Acute Atrophy ... Of the Liver. 

Biliary Concretions, or Gall Stones. 

Icterus Jaundice. 

Other Diseases ... Of the Liver. 

CONGESTION OF THE LIVER. 
Varieties. — 1. Sanguineous. 2. Biliary. 

1. sanguineous congestion. 

Symptoms. — A sense of fulness and weight in the right hypochon- 
drium, rarely amounting to dull pain ; enlargement of the liver, so that 



528 



CONGESTION OF THE LIVER. 



the lower edge can be felt two or three fingers' breadth below the 
margin of the ribs ; sallowness of the complexion, with sometimes 
distinct yellowness of the conjunctiva; in severe congestion, complete 
jaundice ; anorexia ; tongue coated with a white fur ; bowels torpid. 

Morbid Anatomy. — Increase in the size and weight of the liver, 
which is dark-coloured and gorged with blood. If the congestion affect 



Fig. 71. 



Fig. 72.* 





Fig. 73. 



the hepatic and portal veins unequally, the liver has a distinct mottled 
appearance. When the congestion affects only the hepatic vein, the 
lobules have a light border (c) and a dark centre (a) ; the congestion 
is chiefly intralobular (Fig. 71). When the portal vein is alone con- 
gested, the outer portions 
of the lobules are darker 
than their centres, and the 
congestion is said to be in- 
terlobular (Fig. 73). 

Causes. — Diseases of the 
heart and lungs, and tu- 
mours within the chest, 
obstructing the thoracic 
circulation ; functional de- 
rangement of the liver 
itself, with diminished ac- 
tivity of the secreting func- 
tion ; intermittent fever ; 
purpura ; impurity of the 
blood from improper diet and excess of alcoholic fluids. 

Treatment. — When due to heart or lung disease, the same treat- 

* Fig. T2 illustrates a diffuse form of intralobular congestion spreading from 
lobule to lobule. 







INFLAMMATION OF THE LITER. 529 

ment must be adopted as for congestion of the stomach arising from the 
same causes. In all other cases, gr. v pilulae hydrargyri, or gr. iv 
calomelanos, followed, after twelve hours, by a brisk saline purgative, 
should be prescribed, and a light farinaceous diet, and abstinence from 
fermented or spirituous liquors enjoined. 

2. BILIARY CONGESTION. 

Symptoms. — "A bilious attack," viz., vomiting and purging of 
matters highly charged with bile, usually preceded by constipation, and 
accompanied by pain in the hepatic region, some enlargement of the 
liver, and a biliary tinge of the conjunctivae. 

Causes. — Biliary congestion is the effect of excessive functional 
activity of the liver, from overfeeding or indolent habits, or a combina- 
tion of the two. The functions of the liver and lungs are to a con- 
siderable extent vicarious. The digestion and assimilation of animal diet 
is attended by separation of a large quantity of hydrocarbon from the 
blood. If the respiratory function be sufficiently active, this is con- 
sumed in the lungs, and excreted as carbonic acid and water ; but it\ as 
in tropical climates, the respiratory function be insufficient, the hydro- 
carbon is separated by the liver in the form of the fatty acids of the 
bile. This secretion becomes immoderate, the liver is congested with it, 
and occasional relief is afforded by bilious diarrhoea. This result happens 
both to those natives of cold climates who, when resident in tropical 
regions, do not adapt their diet to the altered conditions of their 
existence, aud to those who, in any climate, feed heartily and take little 
exercise. 

Biliary congestion is of course an immediate consequence of closure 
or obstruction of the common bile duct. 

Treatment. — After a dose of calomel or blue pill, free saline pur- 
gation ; abstinence from fermented and spirituous liquors ; plain diet, 
consisting chieflv of farinaceous substances. 



HEPATITIS— INFLAMMATION OF THE LIVER. 

1. ACUTE HEPATITIS. 

Symptoms. — Pain in the right hypochondrium, increased by pres- 
sure, by deep inspiration, by coughing, or by lying on the left side ; dry 
cough ; difficulty of breathing ; shooting pains in the chest ; resembling 
pleurisy ; sympathetic pain in the right shoulder ; yellow tinge of the 
conjunctiva, and sometimes actual jaundice ; high-coloured urine ; 
vomiting ; hiccup ; rigidity of the right rectus muscle ; costiveness or 
diarrhoea. There is also more or less pyrexia. In some cases, the fasces 
are of a clay colour, owing to a deficiency of bile ; in others, the bile is 
in excess, and is rejected by vomiting and stool, 

When the concave surface is affected, the pain is more obscure, and 

2 M 



530 CHRONIC HEPATITIS. 

is referred to the back ; the breathing is less affected ; but the functions 
of the stomach are more disturbed. The same disturbance takes place 
when the left lobe adjacent to the stomach is inflamed ; and when the 
posterior and inferior portion of the organ is implicated, there is more 
or less pain and disturbance of function in the kidney. 

Terminations. — In resolution ; in diffused or circumscribed abscess ; 
in gangrene ; in chronic disease. 

Causes. — All the common causes of inflammation ; external injury ; 
intemperance ; protracted biliary congestion ; dysentery ; pneumonia ■ 
phlebitis of the portal vein or its tributaries. 

Diagnosis. — From pneumonia, by the absence of the local signs of 
that disease ; by the pain in the shoulder ; by the local pain, increased 
by pressure ; by the yellowness of the skin and conjunctiva ; by the 
colour of the urine and faeces ; and in many cases by the absence of 
cough and expectoration. 

From gastritis, by the seat of the tenderness, and by the colour of the 
eye and skin, of the urine and fasces. 

Prognosis. — Favourable. About the third, fifth, or seventh day, 
bilious diarrhoea ; universal free perspiration ; hemorrhage from the 
hemorrhoidal veins ; an abatement of lever. — Unfavourable. Intense 
pain and fever ; the pain confined to a point ; continual hiccup ; cold 
extremities ; obstinate constipation ; rigors and hectic fever, indicating 
the formation of abscess. 

Treatment. — Local depletion by cupping or leeches ; or, when the 
hsemorrhoidal or catamenial evacuations are suppressed, the abstraction 
of blood from the anus ; blisters over the seat of the pain ; brisk saline 
aperients ; saline and antimonial diaphoretics ; mercurial inunction ; 
especially during the inflammatory stage of the disease ; a low diet, con- 
sisting chiefly of farinaceous food. 

2. CHRONIC HEPATITIS — CIRRHOSIS. 

Synonyms. — Hepatitis chronica, diffusa, adhesfva ; interstitial hepa- 
titis ; hob-nailed liver ; gin-drinkers' liver ; chronic atrophy. 

Symptoms. — The early symptoms are very obscure. There is a 
sense ot weight with obtuse pain in the region of the liver, increased 
by deep pressure or by lying on the left side, with enlargement and 
preternatural hardness of the organ, obvious to the touch. During the 
progress of the disease, symptoms of more acute hepatitis, and some- 
times jaundice, aie occasionally present. There is a sense of fulness 
and distension of the stomach, with flatulence, and loss of appetite. 
The countenance is sallow, and the skin harsh and dry ; the patient is 
torpid, inactive, and desponding ; the bowels are obstinately costive ; the 
stools deficient in bile ; and the abdomen enlarges imperceptibly at 
first, and well-marked ascites is usually present when the attention of 
the physician is first called to the case. The ascites increase ; the legs 



CHRONIC HEPATITIS — CIRRHOSIS. 531 

become (Edematous ; the reins of the abdomen are prominent; the 
urine is scanty, and deposits lithates, but rarely or never contains albu- 
men. Symptoms of congestion of the alimentary canal appear: — the 
furred tongue is dryish, there is much thirst, and haemorrhage from the 
bowels or stomach is very liable to occur. The blood becomes much 
impoverished, and slight wounds bleed profusely ; minute capillary 
aneurisms occasionally form in the skin, burst, and bleed freely. Under 
careful treatment the patient may improve for a time, but sooner or 
later the digestion fails, he loses flesh, and becomes anaemic ; a copious 
haemorrhage from the bowels, or profuse diarrhoea, causes great debility, 
and ultimately the patient dies exhausted. 

Pathology. — Diffuse inflammation of the connective tissue of the 
portal canals and interlobular spaces, with effusion of solid products. 
These subsequently undergo organization and contraction, and form a 
dense fibrous network of new connective tissue throughout the liver. 
The contraction of the new material causes obliteration of the smaller 
branches of the portal vein and bile ducts, resulting in atrophy of the 
lobules. Great obstruction to the portal circulation thus gradually 
results, ending in the most irremediable form of ascites and anasarca. 

Morbid Anatomy. — The liver reduced in size, of a light yellow 
colour like bees'- wax, presents a coarse tubercular appearance, its surface 
being studded over with rounded elevations of various sizes, projecting 
from the interior. Capsule thickened and opaque; tissue harder than 
normal, sometimes cutting like gristle ; the cut surface presents inter- 
secting lines of opaque connective tissues, forming a coarse network in 
which the yellow nodular masses are contained. The walls of the 
portal vein are thickened, surrounded by condensed connective tissue, 
and their calibre is much diminished. The gall-bladder is collapsed, 
and contains a little transparent golden-yellow or light ochre-coloured 
grumous fluid. On minute examination, a large portion of the hepatic 
cells are found to be destroyed, and their places occupied by masses of 
light-yellow pigment, scattered through a network of newly-formed 
connective tissue. In other places the cells are shrunken, and are in a 
state of fatty degeneration. The capillaries of the lobules are degene- 
rated, and their place supplied by a few narrow vessels which serve to 
convey the blood into the radicles of the hepatic vein. The bile ducts 
are atrophied, and many of the smaller branches, as well as most of 
the tubular network within the lobules, obliterated. Great enlarge- 
ment of the spleen, and congestion of the portal system. 

Causes. — The acute form ; the abuse of ardent spirits ; the disease 
is very common amongst cabmen, who drink much neat spirits. 

Diagnosis. — Sallowness of the skin, never amounting to jaundice ; 
a dryish tongue, and thirst, preceded or accompanied by a little dull 
pain and tenderness in the right hypochondrium, coming on after the 
age of puberty, is strong presumptive evidence of cirrhosis. Jf th^se 
symptoms occur in a person who has indulged freely in spirituous 
liquors, the case is quite clear. In tuber cvlar peritonitis there is dit- 



532 ABSCESS OF THE LIVER. 

fused pain and tenderness over the whole of the belly, and the sallow 
look of cirrhosis is absent ; the ascites, moreover, is never so great as 
in cirrhosis, and the fluctuation is less distinct, because the fluid is 
retained in pouches formed by the adherent intestines. In cancer of the 
liver the ascites is never very great ; the liver, moreover, enlarges, and 
there is the characteristic cachexia, sweating, and emaciation, and 
eventually jaundice. The nodulated enlargement, known as the "hob- 
nail liver," may be perceived through the parietes, and distinguished 
from the single large round projection caused by a collection of hydatids, 
and from the smooth round tumour near the margin of the liver, 
caused by a distended gall-bladder. 

Prognosis. — Unfavourable, the progress will be downwards and 

rapid. 

Treatment. — I. In the early stage leeches to the region of the liver 
as often as it is tender to the touch ; blisters ; and mercurial prepara- 
tions in small doses, often repeated, with mercurial inunction, so as 
slightly to affect the gums. 

II. The portal circulation must be relieved by saline aperients, given 
every morning, so as to keep the bowels loose. When the intestinal 
canal is healthy, drastic purgatives are often more effective than any 
other remedies. If the digestive powers are much impaired, a course 
of bitter tonics, such as the infusions of gentian, quassia, or calumba, 
with soda, or some preparation of steel, if the patient be anamic. 
The nitric or nitro-muriatic acid internally (Form. 137) may be used 
as a bath (Form. 43). Partial tapping must only be resorted to in the 
extremest urgency, as it is never followed by permanent advantage ; if 
the whole of the fluid be withdrawn, there is danger of fatal ex- 
haustion. 



ABSCESS OF THE LIVER. 



Symptoms. — If in a case of hepatitis severe rigors occur, followed by 
well-marked hectic fever, and the previous continued pain, whether dull 
or acute, be exchanged for a distinct throbbing, there is reason to believe 
that suppuration has taken place. Rigidity of the right rectus muscle 
usually accompanies abscess of the liver. 

The abscess may burst into the stomach, and be emptied by vomiting 
into the colon or duodenum, and be evacuated by the bowels ; through 
the diaphragm into the cavity of the chest, giving rise to empyema : 
into the lung or bronchial tube, and be expectorated; or, it may open 
externally, between the ribs, or below them through the muscles of the 
abdomen or back. In very rare cases, the abscess discharges itself 
into the pericardium, into the pelvis of the kidney, into the ascending 
vena cava, or into the cavity of the abdomen. 

Causes. — Predisposing. Those of the inflammation of the liver 
which precedes it. — Exciting. Phlebitis (leading to purulent deposits 






ACUTE ATROPHY OF THE L1YER. 533 

in the liver and lungs). Dysentery. Operations on the rectum, bladder, 
or vagina. Ulceration of the stomach and intestines. Animal para- 
sites : — Echinococcus, Distomum, and Bilharzia. 

Complications. — Ascites. Inflammation of the organs contiguous 
to the abscess, and through which it ultimately discharges itself. 

Diagnosis. — The nature of the disease will be inferred from the 
colour of the discharged matter, and from the rigors, throbbing pain, 
and hectic fever attending the process of suppuration. 

Prognosis. — This will depend, in great measure, on the direction in 
which the abscess discharges itself, and on the degree of inflammation 
which follows. The prognosis is most favourable when the opening is 
in the parietes of the chest or abdomen. It is extremely unfavourable 
when the abscess bursts into the peritoneum. If it become encysted, 
the health may remain unimpaired for years.. 

Treatment. — If the abscess point externally, it must be brought 
forward by poultices and fomentations, and the matter must be dis- 
charged by a trocar and canula. Such an operation should not be 
performed unless we have reason to infer that there is adhesion between 
the sac of the abscess and the abdominal wall. A generous diet, and 
tonics, especially quinine and the mineral acids, must be prescribed. 



HEPATITIS DIFFUSA— YELLOW or ACUTE ATROPHY. 

Definition. — Acute disease of the liver, probably of an inflam- 
matory nature, leading to total suppression of bile and degeneration of 
the secreting structure. 

Symptoms. — For a variable period of a week or more before any 
positive symptoms appear, there are usually indications of hepatic 
derangement; the bowels are irregular, sometimes purged and some- 
times constipated ; the abdomen is slightly tender, the tongue coated ; 
there is loss of appetite, and headache. Sooner or later the skin 
presents a slight jaundiced tint. After the jaundice has existed for a 
week or fourteen days, or even longer, severe symptoms of biliary 
suppression manifest themselves, and the disease runs a violent course, 
terminating fatally in twelve or twenty-four hours, or more rarely in 
a week. The skin, which was at first cool and dry, now becomes hot, 
and of a deeper yellow colour; the pulse rises to 110-120 ; the head is 
hot and painful ; severe vomiting comes on, first of grey mucus, after- 
wards of blood, clotted, or grumous like coffee-grounds ; haemorrhage, 
from the bowels, uterus (with abortion), and nose, is liable to occur. 
There is pain in the right hypochondrium, and the hepatic dulness is 
found on percussion to have diminished or disappeared, while that of 
the spleen has increased : the bowels are confined, and the stools firm, 
dry, and clay-like, from deficiency of bile ; occasionally they are tinged 
with bile. The urine is normal in quantity and specific gravity, of a 



534 



ACUTE ATROPHY OF THE LIVER. 



Fie:. U. 




dark-brown colour, and gives the reactions of bile pigment. Spontane- 
ous evaporation on a glass slide yields microscopical yellowish crystals 

of leucin and tyiosin in fine 
needles, and bundles or dense 
opaque stellate masses (see Fig. 
74), consisting of crystals of 
tyrosin. The pain in the head 
increases in seventy, violent 
delirium sets in, and is suc- 
ceeded by convulsions, stupor, 
and deep coma; hiccup and 
diarrhoea are often present at 
this stage; the skin becomes 
deeper coloured, and frequently 
covered with petechia and ecchymoses, and the motions are tar-like, 
from the presence of blood. In this condition the patient usually 
dies. Rarely after free evacuation of the bowels, consciousness returns, 
the jaundice diminishes, and recovery takes place. 

Morbid Anatomy.— Liver shrunken, shrivelled, and flabby. Sec- 
tions present a smooth, shining surface, of an ochre yellow colour ; but 
no division into lobules is visible. When minutely examined no trace 
of hepatic cells can be found ; the atrophied hepatic tissue is composed 
of fine yellow or pale molecules ; a little oil in fine spherules ; here and 
there irregular masses of a dark-brown colour, and bundles or radiating 
crystalline masses of tyrosin ; the biliary ducts are everywhere pervious, 
and their lining pale. The gall-bladder nearly empty, containing only a 
small quantity of grey mucus or grumous pale yellow fluid, neutral, and 
giving the ordinary reactions of bile. The blood of the hepatic vein is 
rich in crystals of tyrosin, but this compound is absent from the blood 
both of the portal vein and hepatic artery; decoction of the wasted 
liver deposits much tyrosin and leucin. Leucin and urea are accumulated 
in the blood of the heart. The urine is deficient in phosphate of lime 
and urea, and contains large quantities of leucin, tyrosin, and extractive 
matters of a peculiar nature. The spleen is enlarged and congested; 
and extravasations of blood between the folds of the mesentery are 
occasionally found. (Frerichs..) 

Causes. — Predisposing. Youth ; irregular and dissolute habits : 
syphilis ; pregnancy ; certain miasmata (?) — Exciting. The symptoms 
and morbid anatomy both point to diffuse inflammation of the hepatic 
tissue: — "hyperaemia and grey exsudation in parts not yet broken 
down " have been noticed. (Frerichs.) The obstruction to the portal 
circulation, causing the splenic enlargement and the gastro-intestinal 
congestion, are accounted for by the loss of function of the hepatic cells 
and the consequent collapse of the liver. 

Diagxosts. — Acute atrophy may be mistaken for typhus, pyaemia, 
and yellow fever. There appears to be a close relation between yellow 
fever and acute atrophy of the liver, but whether such be really the 



BILIAEY CONCRETIONS. 535 

case is uncertain. Acute atrophy is known by the shrinking of the 
liver, and by the presence of leucine in the urine. 

Prognosis. — Exceedingly unfavourable. 

Treatment. — At first a powerful emetic, and afterwards a large 
dose of calomel, rbllowed by a strong saline aperient ; hot baths ; leech- 
ing and cupping over the liver, or six leeches applied around the anus. 
An occasional dose (v grains) of quinine in a little water. 



BILIARY CONCRETIONS— GALL-STONES. 

Symptoms. — Biliary calculi give rise to no pain or inconvenience, 
till they become impacted in the gall-ducts. The passing of the gall- 
stone is accompanied by the following symptoms: — Excruciating pain 
in the epigastrium, extending to the right hypochondrium and back, 
occurring in severe paroxysms, with intervals of comparative ease, during 
which there is a dull heavy pain in the epigastrium, generally relieved 
by firm pressure. Nausea, frequent vomiting of a clear sour fluid, and 
constant hiccup, are also often present, and jaundice commonly super- 
venes in the course of the attack. The urine generally contains bile, 
and the motions are pale from its absence. The pulse is infrequent and 
full, or the reverse ; there is profuse perspiration ; or, if inflammation 
be present, febrile symptoms. As soon as the calculus reaches the 
intestine, there is a sudden cessation of the pain. 

Terminations. — In inflammation, followed by suppuration, the 
discharge of the calculus externally, or through some internal organ, as 
in ordinary abscesses of the liver. After the escape of the gall-stones 
into the intestines, constipation or obstinate obstruction of the bowels, 
either immediate, when the stones are large, or remote, when they have 
become the centres of intestinal concretions. Sometimes a large number 
of calculi are found in the gall-bladder and gall-ducts after death, 
though no sign of their presence existed during life. Complete obstruc- 
tion of the common bile duct, and deepest jaundice may exist for several 
mouths, or even years, without preventing the patient from following- 
heavy manual work ; but after a time he lapses into the anaemic state. 
and ultimately dies of inanition. 

Morbid Anatomy. — After long retention of bile from closure or 
obliteration of the common bile duct, the duets in the liver are found 
enormously dilated, while the gland itself is shrunken and atrophied. 
It is of a deep olive colour ; the secreting cells are destroyed, and their 
place occupied by free oil globules and dark biliary granules. 

Diagnosis. — The pathognomonic sign is the excruciating pain re- 
lieved by pressure. When the gall-stones are numerous, their presence 
may sometimes be detected by a rough crepitation under the finger. 
By watching the evacuations, and diluting them with water, they may 
sometimes be seen floating on the surface. If the gall-stone be round 
and smooth, there is presumption in favour of its being the only one ; 



536 ICTERUS. 

but if it present a flattened surface, it may be inferred that there are 
several. The calculi may be as small as peas or larger than a walnut ; 
and they have been found in the intestines of great size, and moulded so 
as to fill and obstruct the canal. They are commonly of a dark-yellow 
brown colour, of soft consistence, and have several flat surfaces. They 
consist of cholesterin and the colouring matter of the bile, sometimes 
blended with carbonate or phosphate of lime. 

Treatment. — I. Opium, chloroform, the hot bath, hot fomentations, 
or emetics to relieve the pain and spasm. The opium may be given in 
doses of a grain, or twenty drops of laudanum, every hour, and the 
enema opii every six hours. Emetics are admis-ible in the absence of 
inflammation, but not when inflammatory symptoms exist. 

II. In plethoric persons, or in those prone to suffer from inflammatory 
diseases, bleeding will do good. It may be followed, in the absence of 
vomiting, bv nauseating doses of tartar-emetic. 



ICTERUS— JAUNDICE. 



SYNONYMS. — Morbus arquatus ; aurigo; morbus regius. 

Symptoms. — Languor; inactivity; nausea; loss of appetite, and 
bitter taste ; and sense of uneasiness or pain in the right hypochondrium. 
The sclerotic of the eye and the w T hole surface of the body are of a 
vellow colour ; the urine is high-coloured, and tinges linen yellow : 
the stools are like clay, but in some cases, like the urine, of a yellow 
colour ; the bowels are usually costive, but diarrhoea is sometimes 
present; in extreme instances, the sweat and saliva are yellow, and all 
objects seen by the patient are tinged of the same colour. The pulse is 
generally slow, yet sometimes, especially when the pain is acute, becomes 
quick and hard, and there is a feverish heat and dryness of the skin. In 
some cases, also, the skin is the seat of troublesome heat and pricking. 
Should the disease be long protracted, petechias and maculae sometimes 
appear in different parts of the body ; the skin, before yellow, turns 
brown or livid : even passive haemorrhages and ulcerations have broken 
out. and the disease has in some instances assumed the form of scurvy. 

Causes and Pathology. — Jaundice is directly produced by the 
transudation of bile through the walls of the distended bile ducts, and 
the contiguous capillaries, into the blood. The ultimate cause of jaundice 
is therefore retention of the bile within the liver. The retention may be 
complete or incomplete. Complete retention is caused by the impaction 
of biliary calculi in the hepatic duct or its main branches, or in the 
common bile duct, by the pressure of cancerous tumours of the pancreas, 
duodenum, pylorus, and of the liver itself; by the pressure of [faecal 
accumulations, and of the enlarged uterus : by inflammation of the 
lining membrane of the ducts causing their occlusion. 

Inflammatory occlusion of the duodenal orifice of the common duct 
may probably be sufficient of itself to cause complete retention. 

Spasmodic closure of the bile ducts was formerly regarded as a fre- 



JAUNDICE. 537 

quent cause of jaundice. It may be a transient cause, but it is highly 
improbable that jaundice of some days' standing is due to spasm. 

Incomplete retention may result from biliary congestion; from the 
effect of certain poisons, especially the poison of serpents ; from mental 
emotion, which may act directly upon the circulation in the liver by 
affecting the nerves distributed to the coats of the portal vein. 

Jaundice is a prominent symptom of the severer forms of intermittent 
and relapsing fevers; it occasionally appears in a milder degree, during 
attacks of typhus fever, pneumonia, and pyaemia. To account for its 
appearance in these latter cases, and in some other conditions where the 
bile ducts remain pervious, Frerichs has propounded the theory of 
" obstructed metamorphosis of bile in the blood." This theory assumes 
that the colourless fatty acids of the bile are absorbed into the blood, and 
are there transformed into biliary pigment. In a state of health this pig- 
ment is transformed by the respiratory process into colourless compounds. 
But in certain diseases, such as pyaemia and pneumonia, in which the oxi- 
dising process (respiration) is defective, the metamorphosis of the biliary 
pigment is incomplete, and faint jaundice or sallowness of the skin, or 
deposits in the urine of a blood-red colour, and deposits of uroglaucin and 
urophsein appear, to indicate the several stages of the metamorphosis. 

The facts upon which this theory is founded are the following : — 
1. " The pure colourless acids of the bile may, by the action of con- 
centrated sulphuric acid, be transformed into chromogene, which upon 
exposure to the air, and still more readily on the addition of nitric acid, 
exhibits alternations of tints corresponding in every respect with bile 
pigment." 2. il The same pigments and colour-producing substances 
(chromogene) which in their properties precisely resemble cholepyrrhin 
(the colouring matter of human bile) are produced by the injection of 
colourless bile into the vascular system of living animals." 3. i( The 
normal presence of a considerable quantity of taurin in the lungs." 
Such a theory is not necessary to account for the production of jaundice 
in pneumonia and pyaemia. Both congestion of the liver and hepatitis 
may produce the slight jaundice occasionally present in these diseases. 
Both of these conditions, the one as a consequence and the other as an 
accident, accompany pneumonia ; and suppurative hepatitis is one of the 
commonest results of pyaemia. Xeither, when we consider analogous 
changes, does the sudden production of jaundice from fear, or other 
intense mental emotion, involve any special difficulties. Sudden fright, 
we know, will often cause an immediate exsudation from the skin and 
alimentary canal, leading, in the latter case, to profuse diarrhoea ; and 
if we imagine a similar relaxation of the biliary ducts allowing of the 
transudation of bile into the equally relaxed capillaries, we shall at once 
understand how the Abbe, as mentioned by Villermi (" Diet, des Scienc. 
Medic," p. 420) became suddenly yellow when a mad dog rushed against 
him. Jaundice is frequently attributed to grief and other depressing 
passions, nor do we deny that it may be so produced ; but we believe 
that if such cases were carefully investigated, in nine out of ten a much 
more palpable cause would be discovered, viz., alcohol, which is so often 
taken to blunt and dispel grief. Several cases have convinced me that 



538 ICTERUS NEONATORUM. 

this agent acts locally by producing inflammatory occlusion of the 
orifice, or of the orifice and some portion of the duodenal end of the bile 
duct. One history will serve for ail these cases, so similar were the 
circumstances attending them. A young robust labouring man in 
perfect health, to allay a sudden vexation, intoxicated himself by drink- 
ing three or four glasses of neat rum. The next day there was anorexia, 
nausea, and some pain and tenderness of the epigastrium. On the 
morning of the third day, the skin was moderately jaundiced, the urine 
contained much bile, the faeces were devoid of it, and the bowels con- 
stipated. The jaundice increased in intensity during the next three or 
four days, and then, under the influence of free saline purgation, 
gradually diminished, and disappeared at the end of twelve days. The 
simple and most obvious explanation of such cases is, that the gastro- 
duodenal inflammation caused by the raw spirit involved the duodenal 
end of the common bile duct, and occluded it, thus preventing the flow 
of bile into the intestine. The mineral irritants appear to act in the 
same way. A patient took, by mistake, five doses of a strong solution 
of acid muriate of iron. It produced epigastric pain and tenderness, 
followed by deep jaundice. 

Diagnosis. — The characteristic symptoms which distinguish this 
from eveiy other disease are, the yellow colour of the skin, conjunctiva, 
and the urine ; and, in most cases, the white or clay-coloured laeces. 

Prognosis. — Favourable. The disease having arisen from a cause 
that admits of easy removal ; such as violent mental emotion, accumu- 
lated fseces, or temporary pressure during pregnancy ; the strength and 
appetite little impaired ; the disease appearing suddenly ; cessation of 
local pain, followed by bilious diarrhoea. The disease, even in mild 
cases, runs a chionic course, the skin rarely recovering its proper colour 
under two or three weeks. — Unfavourable. Deep and persistent jaundice 
with anaemia, acute atrophy, cirrhosis, and cancer of the liver. 

Treatment. — Jaundice from inflammation of the liver, or from 
obstruction of the duct, requires the treatment of hepatitis or of biliary 
concretions. (See those diseases.) When, however, there is no pain 
in the right hypochondrium, no fever, and the paroxysms of acute pain 
due to the passage of gall-stones are absent, the treatment will consist 
in the use of emetics, and of gentle aperients to keep the bowels free. 
In the more strongly-marked cases of jaundice, we may begin the treat- 
ment by administering an emetic 'Foini. 220); and afterwards x to 
xx grs. of calomel, followed within two or three hours by an ounce of 
castor-oil. In cases of less severity, the treatment having been com- 
menced by an emetic, the bowels may be kept free by some saline 
aperient (Form. 259;. 

Icterus Neonatorum. — The jaundice of new-born children usually 
appears a few hours after birth, attains its maximum in three days, 
and disappears in from seven to fouiteen days. The urine contains bile 
pigment, and the motions are pale; the general health is unaffected. 

Causes. — According to Frerichs, " the diminished tension of the 






ORGANIC DISEASES OF THE LIVER. 539 

capillaries in the liver, which takes place upon the stoppage of the influx 
of blood from the umbilical vein, and which gives rise to an increased 
transfusion of bile into the blood." It is difficult to understand how a 
partially empty condition of the blood-vessels of the liver can produce 
increased transfusion of bile into the blood. It is much more reasonable 
to suppose that the jaundice arises from a congested condition of the 
hepatic capillaries. At the time of the ligature of the cord, the pulsa- 
tion of the placental extremities of the hypogastric arteries has altogether 
ceased, or become very feeble, and much of the venous blood has drained 
out of the placenta into the body of the child. Such being the con- 
ditions, a little consideration will show that simultaneous ligature of 
the umbilical vein and hypogastric arteries must cause such disturbance 
of the balance of the circulation as, if uncompensated by the expansion 
of the lungs, will, after a few hours, result in general visceral conges- 
tion — ligature of the umbilical arteries at once producing increased 
pressure on the aortic circulation which is transmitted backwards 
through the heait to the interior cava. 

The jaundice of new-born infants is occasionally caused by con- 
striction, an impervious condition, or congenital absence of the hepatic 
or common bile ducts ; inspissated bile obstructing these ducts is 
another cause. In these cases life may be prolonged for several weeks. 

Treatment. — Mild laxatives, such as syrupus senna;, preceded by 
gr. i to gr. ii hydrargyri cum creta. 



OTHER ORGANIC DISEASES OF THE LIVER. 

The liver is subject to several organic diseases besides those already 
described ; namely, to fatty and waxy degeneration, cancerous, syphilitic, 
and tubercular deposits, serous cysts, and hydatids. 

Fatty* Degeneration. — The symptoms are, a smooth, rounded 
margin felt three* or four fingers' breadth below the margin of the ribs, 
increased dulness of the hepatic region, pale fasces, liability to profuse 
pale diarrhoea. Skin pale, anaemic, waxy and smooth to the touch : in 
drunkards greasy. As there is no impediment to the flow of blood 
through the liver, there is no dropsy or haemorrhage. 

Morbid Anatomy. — Bile ducts empty ; liver enlarged, pale, and 
greasy, or (in drunkards) dark dirty brown, and rotten (the nutmeg 
liver). Cells invaded with fat, and deficient in pigment granules. 
(Fig. 7, b, p. 83.) 

Causes. — Phthisis ; habits of intoxication, and a sedentary life ; 
Bright's disease. The disease admits of no direct amelioration. 

Syphilitic Disease op the Liver occurs in two forms: — 1. 
Simple interstitial hepatitis. 2. Hepatitis gummosa. These forms may 
co-exist in the same liver. 

The symptoms, patholojy, and morbid anatomy of simple interstitial 
hepatitis are those of cirrhosis; the syphilitic variety of the disease, 
however, more frequently results in simple induration without the 



540 ORGANIC DISEASES OF THE LIVER. 

formation of the nodules characteristic of cirrhosis. Hepatitis gum- 
mosa consists in the formation of white depressed deposits, having a 
radiated form, on the surface of the liver, and extending to a variable 
depth into the interior of the gland. In this opaque deposit, whitish or 
yellowish nodules, varying in size from a hemp-seed to a walnut, are 
found. They are composed of oil globules, cells loaded with fat, and 
fibres of connective tissue, being identical in structure with the common 
syphilitic node. 

Albumenoid, waxy, lapjdaceous, or amyloid degeneration 
OF the liver is associated with a similar degeneration of other organs. 
It occurs in syphilitic, rickety, and strumous individuals, and is often 
associated witli fatty degeneration and cirrhosis. The symptoms are 
anaemia associated with albuminuria and uniform enlargement of the 
liver, sometimes to an enormous extent. 

Jforbid Anatomy. — In the early stage the lobular structure is 
unusually distinct, the centres of the lobules are reddish-yellow, trans- 
lucent, firmer than natural, aud sharply denned from the dull grey 
peripheral parts. As the disease advances the whole of the lobule is 
invaded, and when this has occurred they are no longer distinct, and 
the section of the gland presents a smooth, homogeneous, yellowish-red, 
glistening, semi -translucent surface. In advanced stages the liver has 
a waxy lustre, the molecular contents of the normal hepatic cells gra- 
dually disappear and give place to a homogeneous clear substance, which 
fills up the cavity of the cell, and the individual cell membranes can be 
no longer distinguished, so completely is the tissue transformed. The 
walls of the blood-vessels and ducts undergo the same degeneration. On 
moistening the section with solution of iodine, all the parts which have 
undergone the waxy degeneration are coloured deep red, and when sub- 
sequently treated with sulphuric acid, the red colour is changed to a 
dirty violet or blue, similar to that produced in cellulose with the same 
reagents. These reactions have led some observers to the opinion that 
the degeneration is " amyloid." It is as distinct from starch as white 
of egg, being in fact a form of albumen. 

Hydatid Tumours are more common in the liver than in any other 
organ. Symptoms. — A globular tumour in the hepatic region having a 
tense feel and a history of slow, painless growth, aud unaccompanied 
by any considerable derangement of the health, is fairly indicative of 
hydatid tumour of the organ. The tumour may have its seat on the 
under surface of the liver, and by pressure on the portal vein or bile 
duct cause ascites or jaundice. An abscess is always preceded by some 
marks of inflammation. An aneurism of the abdominal aorta may be 
distinguished by strong heaving pulsation, bellows murmur, palpita- 
tion in the belly, and sympathetic pains in various parts of the body. 
Hydatid tumours sometimes attain to an enormous size. They may 
burst into the abdominal cavity, causing severe peritoneal pain, collapse, 
and death in a fewhouis; into the intestine, and be evacuated per 
anum ; into the lungs, when their contents are expectorated. These 
tumours may remain in a state of quiescence for a whole lifetime, but 



ORGANIC DISEASES OF THE LIVER. 



541 



they are a source of constant danger because they may be ruptured by 
any accidental blow or fall. 

Structure of the hydatid tumour. — The tumour (echinococcus veteri- 
Korum) is formed of a restricted development of a species of tape worm, 
the Taenia echinococcus of Siebold. It is composed of a delicate thin- 
walled cyst, called the parent cyst, surrounded by a thick-walled dense 
sac formed partly of an exsudation from the parent cyst and partly 
from a condensation of the hepatic tissue enclosing it. The parent cyst 
is filled with a clear salt fluid, in which are floating multitudes of 
delicate spherical secondary cysts varying in size from a pea to an egg. 
These secondary cysts are called acephahcysts ; the larger contain fluid 
and another brood" of acephalo cysts. The inner surface of many of the 
acephalocysts presents a finely granular appearance ; these granules are 
readily detached ; they are echinococci, and have the appearances repre- 
sented in Fig. 75. 

Fig. 75. 




a, Echinococcus with circlet of hooklets retracted, b, booklets, c d, E. ex- 
panded, e, E. imperfectly developed. /, E. showing suckers. 

The parent cvst and its progeny are very liable to calcareous degenera- 
tion, their delicate walls becoming thickened and hardened by milk-white 
earthy matter. 

Treatment. — Hydatid tumours should be tapped as soon as they 
come near enough to the surface. (See a paper by the Editor, Med. 
Chir. Trans., vol. xlix.) 

Malignant Degenerations are very apt to occur in the liver. 
They assume the several forms of scirrhus, medullary sarcoma, and 
melanosis ; and like malignant degenerations of other important viscera 
are necessarily fatal. They generally occasion a great increase in the size 
of the organ, and sooner or later produce obstinate jaundice and chronic 
ascites. The most common of these malignant diseases is the medullary 
cancer in the form of tumours, varying in size and scattered throughout 
the substance of the liver. They project from the surface, and can be 
felt through the attenuated walls of the abdomen. 

The treatment is palliative, and varies with the symptoms, and the 
existing state of the svstem. 



( 542 ) 



DISEASES OF THE SPLEEN. 



The spleen is very liable to congestion ; it is sometimes the seat of 
inflammation, acute and chronic, usually resulting in simple enlarge- 
ment. It is also liable to waxy degeneration, to tubercular, and to 
syphilitic deposits. These diseases may be treated under the single 
head of 

ENLARGEMENT OF THE SPLEEN. 

Symptoms. — Dull pain in the left side ; dyspnoea ; dry cough ; in- 
ability to lie on the right side ; loss of flesh ; anaemia. 

Complications. — Disease of the liver, an unusual tendency to 
haz-rnorrhage, dysentery, and scurvy, and to the anamic or cachectic 
state, known as leucocythcmia (see p. 262). 

Causes. — Previous attacks of ague ; morbid degeneration, especially 
the deposit of tubercles; morbid softening; diseases of the liver ob- 
structing the hepatic circulation ; enteric fever. 

Diagnosis. — By the situation of the tumour in the left hypochon- 
drium, extending, in extreme cases, to the epigastrium,* the umbilicus, 
and the hypogastrium ; by the tumour being solid and smooth, gene- 
rally of an oblong shape, lying beneath the integuments, and move- 
able. The previous occurrence of ague always affords a probability in 
favour of the tumour being situated in the spleen. 

Treatment. — The use of iodine, externally, and iodide of potas- 
sium, with tonics, internally ; friction, in the absence of pain ; gentle 
aperients and alteratives, and moderation in diet. If the disease have 
been preceded by ague, bark or quinine. 



DISEASES OF THE PANCREAS. 

Symptoms. — The symptoms are still more obscure than those of 
disease of the spleen. Hard cancer is the disease to w T hich this gland is 
most liable. The enlargement of the pancreas is not readily dis- 
tinguished from that of the adjoining viscera ; and it is obviously very 
liable to be confounded with organic disease of the pylorus or duo- 
denum. The symptoms generally present are, a deep-seated pain in 
the epigastrium, nausea, sickness, and emaciation. To these may be 
added, as of occasional occurrence, constipation or diarrhoea, salivation, 
and jaundice. 

Diagnosis. — When the whole gland is diseased the fact is indicated 
by fatty stools. 

Treatment. — The treatment of supposed disease of the pancreas 
must be so shaped as to meet the urgent symptoms that happen to be 
present. Fat should be omitted from the diet. 



I 



( 543 ) 



CHAPTER V. 

DISEASES OF THE URINARY ORGANS. 

1. Diseases of the Kidney. 

2. Diseases of the Bladder. 



DISEASES OF THE KIDNEY. 



Nephritis . 
Other Diseases 

LlTHIASIS 

hematuria 
Ischuria Renalis 
Diabetes 



Inflammation of the Kidney. 
Of the Kidney. 
Gravel. Calculus. 
Bloody Urine. 
Suppression of Urine. 
Immoderate flow of sac- 



Chylous Urine. charine Urine. 

Diuresis Immoderate flow of Urine. 

NEPHRITIS— INFLAMMATION OF THE KIDNEY. 

Varieties. — 1. Suppurative Nephritis. 2. Acute Desquamative 
Nephritis. 3. Chronic Desquamative Nephritis. 

1. ACUTE SUPPURATIVE NEPHRITIS. 

Symptoms. — Deep-seated pain and tenderness in one or other loin ; 
numbness in the thigh ; frequent nausea and retching ; more or Ipss 
irritability of the bladder, and pain on mictuiition; considerable 
pyrexia ; urine presenting a white finely granular deposit, which on 
examination is found to consist of pus cells, free or contained in casts of 
the uriniferous tubes. (See Fig. 34, p. 138.) If an abscess form, 
it may burst into the pelvis of the kidney, and be discharged by 
the urethra; or it may point in the loin or groin, which parts pre- 
viously become full and tender. Free suppuration is accompanied by 
hectic fever, under which the patient often sinks. 

Causes. — Morbid conditions of the blood. External violence. Re- 
tention of urine. Renal calculi. 

Morbid Anatomy. — Kidneys enlarged, congested, with scattered 
abscesses, varying in size fiom a walnut to a hemp-seed. Tubes stuffed 
with epithelial cells or pus corpuscles. If a calculus have been the 
cause of the disease, the kidney will probably be found destroyed, and 
its outer portions converted into the sac of a large abscess which occu- 



544 ACUTE DESQUAMATIVE NEPHRITIS. 

pies its interior. Calculi usually lie in the pelvis of the kidney, and 
are the cause of suppurative inflammation of its mucous membrane 
(pyelitis). They ultimately lead to ulceration of the mamillae, and 
degeneration of the entire kidney. 

Diagnosis.— Pus, derived from the kidneys, is moulded into tubes. 
The symptoms of inflammation of the pelvis are great renal pain and 
irritation, and the passage of large quantities of free pus. 

Treatment. — In the early stage, cupping or leeching of the loin. 
Hot baths. A brisk saline purge followed, by full doses of compound 
ipecacuanha powder, and acetate of ammonia. In the latter stages, 
quinine with the mineral acids, or alone, may be given. If the inflam- 
mation be due to calculi, we must treat accordingly. (See Renal Calculi.) 



2. ACUTE DESQUAMATIVE NEPHRITIS. 

Symptoms. — In most cases slight rigor and pyrexia ; pain in the 
loins and legs ; headache ; in some cases vomiting. In the course of a 
few days the face becomes pallid and swollen, and the legs at the same 
time (Edematous. Ultimately there is general anasarca. 

During the first few days the urine is very scanty, or even sup- 
pressed. It is of a dark-brown or red colour from admixture of blood, 
and loaded with albumen. The pain in the loin persists, and on deep 
pressure there is much tenderness. Sometimes the pain is severe, and 
extends down the ureter to the bladder and thence to the testicles and 
down the inside of the thighs. Nausea and vomiting accompany these 
symptoms. Inflammation of the serous membranes is very liable to 
occur during the existence of the febrile symptoms. Sometimes con- 
vulsions and coma (grave symptoms of suppression) suddenly supervene. 

If the case progress favourably, the quantity of urine increases, and 
deposits a little cloud of flocculent matter, and the blood disappears. 
After a week it may become quite clear, and remain of a pale colour 
and low specific gravity ; it constantly contains albumen, the quantity 
of which is variable. As convalescence approaches, it diminishes to a 
mere trace, and the quantity of urine increases ; sometimes as much as 
120 ounces being voided in the 24 hours. The anasarca now gradually 
disappears, and the patient is ultimately left much emaciated and very 
weak. If the disease terminate fatally, death is preceded bv diminu- 
tion of the urine, until at last there is total suppression. Death more 
frequently occurs in the latter stages from chest complications, resulting 
in apncea. 

Causes. — Scarlatina, measles, erysipelas ; abuse of alcoholic liquors ; 
suppression of the cutaneous excretions from exposure to wet and cold. 

Pathology. — Excessive functional activity of the kidney, induced 
by a suppression of the cutaneous excretion, or in the attempt to 
eliminate certain poisonous matters from the blood. This leads to 



ACUTE DESQUAMATIVE NEPHRITIS. 545 

active congestion and excessive growth of secreting epithelium, the 
cells of which, being changed in this abnormal process, become at last 
inadequate for the performance of their own special function — the 
elimination of the urinary constituents. These, in part, remain in the 
blood, and give rise to the characteristic symptoms of the disease. 
Meanwhile the capillaries of the kidney become dilated or even rup- 
tured, and the constituents of the blood escape into the renal tubuli. 
The blood becomes much impoverished ; the albumen and red corpuscles 
diminish, and the specific gravity of the serum falls from 1030 to as 
low as 1020 in some cases. But what is of more serious import still, 
urea accumulates in such quantities in the blood, that its presence may 
be detected in effusions in distant parts of the body. 

The fatal symptoms of urinary suppression are due to the presence 
of urea in the blood. At first the stomach endeavours to eliminate it, 
and hence the vomiting ; but this vicarious function is insufficient : 
the poison accumulates, and its action is manifested in the convulsions 
and coma which terminate life. It is considered by some that urea, as 
such, has no poisonous influence, and that the terrible symptoms of 
suppression only come on when this is converted into ammonia. 

Morbid Anatomy. — In death during an acute attack. Both 
kidneys are found involved. They are enlarged and congested, and of 
a dark-red or chocolate colour; the structure as firm or a little firmer 
than natural ; the cortex more or less mottled with spots of anaemia 
and ecchymosed tissue ; the medullary cones are uniformly congested. 

On minute examination the uriniferous tubuli are found, some 
crowded with epithelial cells, others filled with blood, giving rise to 
the ecchymosed spots observed on the capsular surface and in the 
interior of the gland ; in others the clot has become colourless. 
Here and there blood may be observed effused into the capsule in- 
closing the Malpighian tufts. The walls of the capillaries themselves 
are thickened and opaque. The pelvis of the kidney, the ureters, and 
sometimes the bladder are congested, and there is general congestion of 
the internal organs and effusion into the serous cavities. The bladder 
is usually empty. If the disease have continued for a month or more, 
the kidneys will be found in one or other of the stages of degeneration 
described under Chronic Desquamative Nephritis. 

Diagnosis. — (Edema commencing in the delicate areolar tissue of 
the eyelids, nymphse, or scrotum, followed by pufhness of the face and 
general anasarca; the dark smoky colour of the scanty urine, which is 
found to deposit blood corpuscles and casts of the uriniferous tubules 
filled with epithelial cells (Fig. 30, p. 137), are the signs by which 
acute desquamative nephritis, and its attendant dropsy, may be distin- 
guished from other renal affections, and dropsies dependent on hepatic, 
pulmonary, or cardiac diseases. 

Prognosis. — Favourable if the secretion of urine be free, and con- 
tain comparatively little blood and albumen. Unfavourable if the 
urine be very scantv and bloody, and if difficulty of breathing come on. 

2 N 



546 CHRONIC DESQUAMATIVE NEPHRITIS. 

Treatment. — I. Reduce the inflammation, either by the use ot 
cupping-glasses, or the application of numerous leeches to the region of 
the kidney, followed by mustard-poultices. 

If there be much febrile action, tartarized antimony, in diaphoretic 
doses, will be of much service. When pain is a prominent symptom, 
Dover's powder may be given in combination with the antimony. 

II. Restore the action of the skin. — The hot bath, or, still better, a 
hot-air bath, should be given, and acetate of ammonia simultaneously 
administered, in order to secure copious diaphoresis. 

The temperature of the room should be kept above 70° Fahr. 

III. Relieve the action of the kidneys. — Saline purgatives, in com- 
bination with senna or jalap, should be given, so as to keep the bowels 
freely open. The diet must be restricted to gruel and farinaceous sub- 
stances. Toast or barley-water may be freely taken. 

IV. If symptoms of suppression appear, the treatment recommended 
under Ischuria Renalis (see p. 555; must be adopted. 

3. CHRONIC DESQUAMATIVE NEPHRITIS. 

Symptoms. — These are insidious, and may long remain unobserved. 
The disease is a frequent consequence of a slight attack of the acute 
variety, and we may generally trace back its origin to an indisposition 
caused by exposure to wet or cold. In many cases it appears to have 
crept on in consequence of gradual degeneration of the kidney. Many 
patients present the gouty diathesis, or are actually suffering from a 
renewed attack when the renal symptoms first appear. Emaciation, 
and anaemia, with an inclination to swelling of the eyelids and ankles, 
are the symptoms of debility which induce the patient to apply for 
relief. On inquiry we shall probably rind that micturition is copious 
and frequent, that the patient is frequently disturbed several times in 
the night to void urine. In gouty subjects the urine is usually scanty 
and loaded with lithates, and will be found to contain a variable 
• quantity of albumen and casts of the uriniferous tubules resembling 
those which have been already described as characteristic of acute 
desquamative nephritis. The patient may remain in this state for 
months or even a few years, but at last dropsy comes on and becomes 
general, the urine decreases, the casts show great degeneration of the 
epithelial cells, and have a granular appearance (Fig. 31, p. 137); 
sometimes the cells are altogether absent, the cast itself looking like a 
film of wax, to which drops of oil are, in the latter stages, observed to 
adhere. Urea accumulates in the blood ; the patient is seized with 
epileptic fits, which succeed each other in rapid succession, and he 
finally becomes comatose and then dies. 

Morbid Anatomy. — The kidneys are more or less atrophied and 
shrunken, weighing sometimes not more than 1J ounce ; the tubuli in 
part completely denuded of epithelium, and atrophied; the cortex con- 
tracted and reduced to a narrow layer covering the bases of the cones, 
and the Malpighian bodies more closely approximated. Some of the 



CHRONIC DESQUAMATIVE NEPHRITIS. 547 

tubuli present dilatations, which, by becoming isolated and further dis- 
tended, are converted into cysts containing a clear albuminous and often 
jelly-like fluid. The intertubular tissue has a fibrous appearance. The 
capsule is generally firmly adherent, and the surface from which it is 
removed granular. The granulations are composed of aggregations 
of degenerated tubules lying between the small branches of the renal 
vein. This condition very much resembles that of cirrhosis of the liver. 
If the disease have had its origin in gout, the kidneys will be small and 
atrophied, as in the last stage of chronic desquamative nephritis, but 
they will present the characteristic appearance described at p. 359. 

If the chronic disease be a sequence of the acute variety, we may 
meet with two other morbid conditions of the kidney, viz., the " large 
white kidney" and the "red coarse mottled kidney," both of which 
may be regarded as intermediate stages between the swollen con- 
gested kidney, characteristic of the first stage of acute desquamative 
nephritis, and the small contracted kidney, the last stage of chronic 
desquamative nephritis. The coarse red mottled kidney is found in 
those who have abused spirituous liquors : it is a mixture of con- 
gestion and fatty degeneration, the white spots which mottle the en- 
larged cortex, and the white lines which streak the pyramids being 
composed of fat. 

Pathology. — Complications and Terminations.— In conse- 
quence of the destruction of the secreting epithelium of the kidneys, 
the blood becomes contaminated with the constituents of the urine. 
The effects of the circulation of this impure blood are general. 1. The 
affinity between the growing and secreting structures and the blood is 
diminished, the capillary circulation is feeble and sluggish, and the 
heart, in its endeavours to overcome the impediment, becomes hyper - 
trophied and dilated. Failing in its efforts, general anasarca is the 
result. — 2. The gastro-intestinal and pulmonary mucous membranes 
take on an action vicarious of that of the kidney, and endeavour to 
eliminate the urinary constituents : vomiting, diarrhoea, and bronchitis 
are the consequences.' — 3. The impure blood tends to produce low forms 
of inflammation in various parts of the body ; peritonitis, pleuritis, 
pneumonia, and if the skin be slightly wounded, erysipelas, may arise as 
complications at any time. The brain itself is sometimes affected, and 
fluid containing urea poured out into its ventricles. This is always the 
ultimate result when death occurs from suppression of urine. 

Diagnosis. — For the differential diagnosis of Dropsy, see p. 271. 
Renal dropsy is known from other varieties : 1. By the absence of long- 
standing pulmonary, cardiac, or hepatic disease ; 2. By the mode of 
access, appearing first in the face, particularly the eyelids, on rising in 
the morning, and by slight pufflness of the ankles and scrotum towards 
evening ; and 3. By the condition of the urine, from which the several 
stages of renal degeneration may be safely inferred. If the tubular 
casts be composed of epithelial cells in a state of granular degeneration, 
we may assume that the kidney is in the second stage of degeneration. 
If the casts be large, and wholly denuded of cells, the degeneration is 



548 DISEASES OF THE KIDNEYS. 

still further advanced. If these denuded casts contain oil globules, the 
organ may be regarded as in the last stage of atrophy. 

Prognosis. — The prognosis will depend, as Dr. George Johnson has 
so ably shown, upon the evidence furnished by the microscope as to the 
condition of the kidney, indicated by casts of the uriniferous tubules, to 
which reference has been made under Diagnosis. In the early stage of 
chronic as well as of acute desquamative nephritis recovery may be hoped 
for in the absence of any serious complications. In the later stages the 
prognosis is unfavourable. In the intermediate conditions the progress 
of the disease may, under favourable circumstances, be arrested. 

Causes. — Predisposing. The scrofulous diathesis. It occurs in both 
sexes, and at all ages. Of seventy-four fatal cases recorded by Dr. Bright, 
nineteen were under thirty, fifty under fifty, thirteen above fifty, and 
four above sixty. — Exciting, Those of the acute varieties of the disease. 
The impure air, and other unwholesome influences to which the poor 
inhabitants of large towns are exposed ; intemperance ; mechanical 
injuries ; cold ; a previous attack of scarlatina, followed by dropsy ; 
rheumatism ; gout. 

Treatment. — Relieve the congestion of the kidney, and the attend- 
ant dropsy, by purgatives and diaphoretics, diuretics being inadmissible. 
In the absence of diarrhoea, a drastic purgative, such as a full dose of 
the compound jalap powder, may be given every morning ; at the same 
time five or ten grains of Dover's powder may be occasionally prescribed 
to act upon the skin. When there is much debility, stimulant dia- 
phoretics, such as the liq. ammon. acet. in doses of 5ii to 5iv three or 
four times a day, are indicated. The warm bath, or the hot-air bath, 
may be used at intervals of one, two, or three days. The skin should 
be kept warm. 

To imp/rove the health. — A nourishing and unstimulating diet should 
be prescribed; and preparations of steel, of which the tinctura fern 
perchloridi (in doses of TT\ xx or 3ss) is the best. 

In the treatment of complications, pathology of the disease must be 
duly regarded ; vomiting may be checked, but purging, we must remem- 
ber, is a natural safety valve, and we must do no more than restrain it, 
if it become immoderate. If the oedema of the legs increase, and the 
skin become painfully tense, much relief will be afforded by acupuncture, 
or slight incisions made on the outside of the legs. 

Prophylaxis. — Temperance, pure air, a warm, dry climate, plain 
and wholesome diet, and regular exercise, are needful for persons who 
have had, or who seem liable, to nephritis. 



OTHER DISEASES OF THE KIDNEY. 

The kidney, in common with other vascular organs, is liable to many 
other forms of disease. Some of these may affect the kidney alone ; 
others are associated with similar disease of the neighbouring viscera. 



DISEASES OF THE KIDXETS. 549 

So long as one kidney only is affected, the urinary function is unim- 
paired, the healthy organ becoming hypertrophied and performing double 
duty. The following are the diseases most commonly met with : — 

I. Cystic diseases. — Cysts in the kidney, varying in size from a mus- 
tard-seed to a marble, are of very frequent occurrence in the cortical part 
of the kidney. The atrophied kidney of chronic nephritis, very com- 
monly presents a large number of minute cysts. It is sometimes en- 
larged and tabulated, and converted into a few large cysts filled with 
glairy fluid, the intervening secreting structure being destroyed. There 
can be little doubt that these cysts are formed by obstruction and obli- 
teration of one part of the denuded uriniferous tubules, while other 
portions are distended into cysts by the secretion of albuminous fluid. 

When an ureter becomes obstructed or obliterated, at first urine, and 
then a watery fluid, continues to accumulate in the pelvis of the kidney, 
the secreting structure being slowly absorbed by the pressure, and the 
whole organ finally converted into one large cyst. A similar change 
may result from an impediment to the flow of urine from the bladder, 
the ureters becoming dilated to the diameter of the small intestine. The 
term hydro-nephrosis has been employed to indicate the presence of such 
cystic tumours of the kidney, 

The kidney is liable to morbid changes resembling those which com- 
monly affect the ovary and give rise to ovarian dropsy. In one case 
which came under my notice, the symptoms were so precisely similar 
that the case was treated throughout for ovarian disease, the abdomen 
being uniformly and excessively enlarged, dull, and distinctly fluctuant 
on percussion. After death both ovaries and the other genital organs 
were found perfectly healthy, and had contracted no adhesions with the 
tumour. This, which weighed forty-five pounds, was contained within 
a smooth-walled cyst ; the ureter and upper end of the left kidney 
were directly continuous with the smooth wall of the tumour. There 
were two principal cysts, which contained together nine pints of fluid, — 
colourless in one of the cavities, and dark-brown in the other. The 
right kidney was healthy and hypertrophied. This patient had had 
two children ; her age was thirty-four. Another case, presenting 
exactly the same symptoms, and, generally, the same morbid appearances 
in connection with the left kidney also, occurred at the Stockport In- 
firmary during my residence there. The subject was a little girl about 
seven years of age. The abdomen was greatly distended as if by the 
gravid uterus. The age of the patient somewhat simplified the diagno- 
sis ; a tumour of the uterus it could hardly be, and ovarian disease 
seemed just as improbable ; but yet from the uniformity of the swelling 
which had commenced in one iliac region, its fluctuation, and the ab- 
sence of any urinary symptoms, most of those who formed a positive 
diagnosis concluded that it was ovarian. 

II. Fatty degeneration (the granular kidney). — This is the condition 
to which the atrophied kidney of desquamative nephritis tends. The 
glands are large and pale, the cortex is anaemic, and mottled with 
opaque granulations of a yellowish- white colour, giving a granular 
appearance to the kidney. On minute examination the granulations 



550 LITHIASIS. 

are found to be composed of fat, and the convoluted tubuli are lined 
with dark opaque ceils composed of fatty molecules and drops of oil 
(Fig. 8, p. 83). _ 

The early symptoms are those of desquamative nephritis ; afterwards 
the pale albuminous urine is rather scanty and quite clear, occasionally 
depositing a little cloud of small waxy casts, in which minute globules 
of oil are found adhering. 

III. Albumenoid (waxy, lardaceous, amyloid) degeneration. — The 
kidney, in common with other glands, is liable to this form of disease. 
The gland is usually increased in size ; it is hard, and cuts firm; the 
surface of the section is smooth, homogeneous, and of a waxy appear- 
ance. The minute structure of the degenerate tissue is that already 
described under Albumenoid Degeneration of the Liver. (See p. 540.) 
This condition of the kidney appears to be derived from the " large 
white kidney," found in the second stage of acute nephritis. Perhaps 
the scrofulous diathesis, with which the albumenoid kidney is most 
frequently associated, determines the particular pathological condition 
into which the large white kidney may branch. The term " albu- 
menoid" is selected to designate this form of degeneration, because the 
morbid material is of the nature of albumen. " Lardaceous " and 
" waxy " are only appropriate in so far as they refer to appearances. 
The term amyloid is exceedingly inappropriate. 

The symptoms of the disease are those of chronic desquamative 
nephritis. 

IV. Tuberculous and cancerous deposits occur in the kidney, asso- 
ciated with similar disease elsewhere, rarely or never alone. They 
form at first isolated rounded masses, which tend to become confluent 
and soften in the centre, and being discharged with the urine, may be 
identified, and the condition of the kidney inferred therefrom. 

V. Hydatid tumours of the kidney are uncommon. 



LITHIASIS— GRAVEL axd CALCULI. 

Symptoms. — Dull or acute pains, with a sense of heat and heaviness 
in the loins ; with more or less pain or difficulty in voiding urine, in- 
creased by sudden and violent motion, with occasional pain behind the 
pubes ; irritation at the neck of the bladder, and itching or pain at the 
end of the penis. Sometimes there is retraction of the testicles, with 
discharge of bloody urine, or of clots of blood. The urine, even while 
warm, contains a sandy powder, crystalline grains, or small calculi. 
It is generally rather scanty, high-coloured, of high specific gravity, 
acid, of a strong odour, and becomes turbid on cooling. The digestive 
organs are deranged, and the patient suffers from ascidity, flatulence, 
and frequent eructation ; constipation ; furred tongue ; dry skin ; rest- 
lessness ; and feverishness. 

The most common form of gravel consists of urate (lithate) of am- 
monia, with or without free uric acid (red gravel). Next in point of 



GEAYEL AND CALCULI. 551 

frequency, is pure uric acid. The ammoniaco-magnesian phosphate, or 
a mixture of this with amorphous phosphate of lime (white gravel) 
comes next in order ; then the oxalate of lime. These deposits may 
co-exist or alternate with each other. When the deposits become ag- 
gregated to form small calculi, the symptoms are much more severe. 
(For the mode of distinguishing these several varieties see pp. 126, 
et seq.) 

The symptoms of calculus in the kidney are those of gravel in its 
most severe form, viz., pain in the loins, extending to the groin, testicle, 
or extremity of the penis, retraction of the testicle, painful and frequent 
micturition, and bloody urine. Nausea and vomiting, restlessness, and 
slight fever. These symptoms are often suddenly removed by the 
discharge of a small calculus, accompanied or not by that of a large 
deposit of gravel. If the calculus remain in the kidney, it often leads 
to severe suppurative inflammation {pyelitis), and its complications 
(p. 544). 

The symptoms of Calculus in the Ureter. — When a calculus is 
passing along the ureter, there are paroxysms of intense pain (a fit of 
the gravel), or a dull pain along the affected ureter and spermatic cord 
on the same side, extending to the penis, the testicle, or the inside of 
the thighs. There is frequently great tenderness in a circumscribed 
part of the abdomen, corresponding with the seat of the calculus. The 
patient is troubled with constant and often ineffectual calls to pass 
urine, which is tinged with blood. There are severe nausea and vomit- 
ing, and intense suffering. These symptoms may pass off suddenly, 
as soon as the calculus reaches the bladder, followed, in some cases, by 
its discharge from the urethra. In other instances, the calculus re- 
mains impacted in the ureter, leading to disease of the kidney, or giving 
rise to large accumulations of urine, with distension of the ureter, of the 
pelvis, and even of the walls of the kidney itself. The kidney thus en- 
larged has grown to such a size as to fill the abdomen (hydro-nephrosis), 
and be mistaken for ascites. 

The symptoms of calculus in the bladder are, frequent desire to pass 
water ; during its passage a burning sensation at the orifice of the 
urethra ; sudden interruptions of the stream, accompanied by great 
forcing and intolerable pain ; after lying on the back the urine again 
flows ; the discharge of the last ounce is attended with excruciating- 
pain, caused by the contraction of the bladder upon the stone ; fre- 
quently there is numbness and tormenting pain down the inside of the 
thigh. After violent exercise, or long continuance of the symptoms, 
the urine becomes purulent and bloody from inflammation of the 
mucous membrane of the bladder. 

Causes. — Predisposing. Childhood, and from the age of forty 
upwards ; high living ; sedentary habits ; rheumatic and gouty dia- 
thesis. — Exciting. Cold ; blows and injuries to the loins ; parasites 
(p. 554) ; dyspepsia ; the use of water containing calcareous matters. 
In the case of the oxalate of lime gravel, an excess of saccharine matters, 
and vegetables and fruits containing oxalic acid ; organic disease of the 
kidney or bladder. 



552 HEMATURIA. 

Treatment. — This varies with the species of gravel discharged. 

In uric lithiasis a diet chiefly vegetable, and in extreme cases entirely 
so, with total abstinence from fermented liquors and wines. Diluents; 
the bicarbonate of potash (Form. 295), and salts of lithia (Form. 294), 
taken in a tumbler of cold water an hour before meals, three or four 
times a day, so long only as the urine has an acid reaction. The alka- 
line aerated waters of Vichy and Carlsbad. 

In pkosphatic lithiasis a more generous diet is admissible, with a 
moderate allowance of wine, and the mineral acids fthe nitric, muriatic, 
or nitro-muriatic acid), should be given at short intervals. When the 
phosphatic diathesis has been brought about by exhaustion of mind or 
body, opium very often proves very serviceable. 

In oxalic acid lithiasis, mineral acid. All articles of food containing 
oxalic acid should be avoided, and saccharine substances should be taken 
in moderation, or, in extreme cases, disallowed. The patient should 
use soft water. 

In all forms of gravel, strict attention must be paid to the general 
health ; to the functions of the skin and bowels, and to the state of the 
digestive organs. Warm bathing is beneficial by promoting the action 
of the skin. 

In the treatment of renal calculi, our efforts must be directed to 
relieve pain and facilitate the passage of the calculus. The medical 
treatment of calculus in the bladder will depend upon the nature of 
the gravel voided by the patient. 



HEMATURIA— BLOODY URINE. 
Symptoms. — An evacuation of blood in the urine. 

Causes. — Congestion of the kidney, or of any part of the mucous 
membrane of the urinary organs, idiopathic, or produced by cantharides, 
turpentine, &c. ; nephritis ; calculus in the kidney, ureter, bladder, or 
urethra ; blows on the loins ; diseased prostate ; chronic inflammation 
or ulceration of the mucous membrane of the bladder ; villous tumours 
or malignant fungous growths from the mucous membrane. Some- 
times hsematuria occurs in the course of purpura nautica, or purpura 
hsemorrhagica, typhus and scarlet fevers. The strongylus gigas, a 
nematoid worm, is a rare cause of hsematuria. In the West Indies, 
Egypt, the Mauritius, Natal, and Cape of Good Hope, hsematuria is 
endemic, and it has been traced in some of these countries to the presence 
of animal parasites in the urinary organs. 

Diagnosis. — Bloody urine is of a bright-red or dark-brown colour, 
and if the quantity of blood be considerable, a dark-brown deposit, 
or distinct coagula are formed. For the chemical and microscopical 
characters, see p. 134. When the secretion is acid, and the blood in 
very small quantity, the urine has a smoky appearance. 

The source from which the blood flows may sometimes be inferred 



ENDEMIC HEMATURIA. 553 

from the accompanying symptoms, and a careful examination of the 
urine. If the haemorrhage be preceded by pain in the region of the 
kidney, if the blood be equally diffused through the urine, and if it 
contain casts of the urinary tubes (see p. 137), the blood is from 
the kidney. When the first quantity of urine discharged from the 
bladder is little, if at all, tinged with blood, and the remainder 
consists of blood, or urine highly tinged with blood, there is a strong 
presumption that the haemorrhage is from the bladder, especially if 
symptoms of stone are present. When the blood flows without dis- 
charge of urine, it is derived from the urethra. 

Treatment. — Must be determined by the probable cause of the 
haemorrhage. If the disease be the consequence of injury, or the 
patient be of a full, plethoric habit, cupping of the loins, rest, and 
geutle aperients will be required. If it arise from irritation of the 
kidney by calculus, together with the remedies proper for that disease, 
frequent draughts of mucilaginous liquids, as thick barley-water, solu- 
tion of gum acacia, decoction of marsh-mallows sweetened with honey, 
opium, and copious emollient clysters should be prescribed. If the 
blood coagulate in the bladder, and give rise to difficult micturition, 
the catheter must be used, and injections of warm water, decoction of 
marsh-mallows, or of poppies, be resorted to. 

When the haemorrhage is excessive, cold water, or a cold solution of 
alum f^j-Oij) may be injected into the rectum. At the same time the 
vegetable astringents (Form. 170, 172) may be given by the mouth. 
Acetate of lead with opium, and tinctura ferri perchloridi are suited to 
the anaemic. 

EXDEMIC HEMATURIA. 

One of the above-mentioned causes of haematuria is so widely pre- 
valent amongst the inhabitants of certain regions that it requires sepa- 
rate consideration. The disease is known to be endemic in the West 
Indies, in Egypt, in the Mauritius ; and I have lately (Med.-Chirurg. 
Trans., 1864) called attention to its existence in Natal and the Cape of 
Good Hope, at Uitenhage and Port Elizabeth. 

Dr. T. Bilharz, of Cairo, has shown that the haematuria and gravel 
(lithiasis) so common in Egypt is due to the presence of a nematoid 
worm, variously termed Distomum haematobium, Gynaecophorus haema- 
tobius, and Bilharzia haematobia. It is a minute white worm, less than 
half an inch long. In [Fig. 76, the female (a b c d; is represented 
partly lying within the gynaecophoric canal of the male (c) ; the eggs 
(e) are considerably magnified. The parasite inhabits the veins of the 
urinary and portal systems, but more commonly those of the former, 
causing much congestion and hypertrophy of the mucous membrane of 
the bladder, ureter, and pelvis of the kidney. 

The haematuria of the south-east coast of Africa is due to the same 
or a closely-allied species of parasite. Only the eggs and ciliated embryo 
(Fig. 77) are at present positively known. There can be little doubt 
that the disease prevalent in the Mauritius is due to the same animal. 



554 



ENDEMIC HEMATURIA. 



The cause of endemic hematuria of the West Indies remains to be 
discovered. 

Symptoms. — The symptoms of the disease prevalent in South Africa 
and the Mauritius are the following: — The passage, with the last 

ounce of urine, of a little blood, 
Flg -' 6, rarely exceeding a teaspoonful; 

or bloody, or colourless mucus, 
moulded so as to resemble " veins." 
These latter sometimes cause a little 
obstruction, and give rise to strain- 
ing. When the parasite inhabits 
the kidney, an occasional smart 
twinge of lumbar pain is felt. The 
urine is clear and pale-coloured, 
the blood being rarely or never dif- 
fused through the bulk of it. After 
exertion, the quantity of blood 
is increased. During the earlier 
years of the disease no other pain 
or inconvenience is experienced. 
The disease attacks both sexes at 
about the age of ten. My friend, 
Mr. Dunsterville, of Port Eliza- 
beth, informs me that two out of 
every three schoolboys are affected, 
and their linen is commonly blood- 
stained like that of the other sex 
from the menstrual discharge. 
Adults, and occasional residents of certain localities in the Cape and 
Natal, are also liable to the attacks of the parasite. 

After a few years the hematuria gradually declines, and, as a rule, 
entirely disappears at the age of puberty ; but the cause, as manifested 
by the presence of ova in the urine, persists, and sooner or later gives 
rise to severe symptoms of gravel. The urine assumes a highly saline 
condition, and crystalline deposits, chiefly composed of oxalate of lime, 
form around the ova which the parasite produces in great abundance. 
The eggs thus become the nuclei of renal calculi. 

Diagnosis. — The presence of the characteristic ova a b (Fig. 77), 
in the urine. They measure the p^th of an inch long, and the ^th 
broad, and are strongly acuminated. The colourless or bloody mucus 
casts, a, frequently contains scores of these ova. Occasionally the 
ciliated embryo c may be observed escaping from the egg d. 

Cause. — The introduction of the parasite in an early stage of 
development into the stomach by means probably of water, or of certain 
water plants or salads. 

Prophylaxis. — The use of filtered or boiled water, and prevention 







SUPPRESSION OF URINE. 



555 



of the contamination of the streams by the urinary products of indi- 
viduals suffering from the disease. 

Fig. 11. 




Treatment. — This must be directed : I. To kill or expel the adult 
sexual parasites. II. If our efforts to do so be unavailing, to secure 
the regular expulsion of the ova which, so long as they remain in the 
body, may at any time become the nuclei of urinary calculi. The success 
which attends the treatment of intestinal parasites leads one to hope 
that some specific may be found against the Bilharzia which in its after 
consequences is a most painful, and sometimes a dangerous associate. 
To get rid of the parasite, which is not simply attached to the surface 
of the mucous membrane, but lies within orifices of the smaller veins, 
we must introduce into the blood a remedy poisonous to the parasite. 
Atropia and hyosciamia are two principles which are solely eliminated 
by the kidney, and it appears veiy probable that a persevering use in 
belladonna and henbane would retard the development of the parasite 
even if it did not result in its destruction. These remedies are at the 
same time most beneficial in allaying the irritation from the crystalline 
deposits which form around the ova. 



ISCHURIA RENALIS— SUPPRESSION OF URINE. 

Symptoms. — Languor, restlessness, weariness and weight in the loins 
and legs, frequent pulse, heat of skin, flushed face, headache, nausea, 
and vomiting. About the third day drowsiness and oedema of the face, 
or general anasarca, follows. Some hours afterwards epileptiform con- 
vulsions, often very violent and frequent, come on, and alter three or 
four attacks the patient falls into a state of profound coma, and dies. 
At the onset, a small quantity of muddy urine may be voided ; but 
when the disease is fully formed, there is anuria or complete suppression. 

In some cases, there is neither pain in the loins nor fever, but only 
slight nausea and drowsiness. During the second or third day the 



556 DIABETES. 

patient becomes comatose, and dies in from 24 to 30 hoars. In some 
cases, the suppression is a consequence of retention of urine in the 
kidney from obstruction of the ureters, and in these the disease sets in 
with excruciating pain, which at length subsides ; and the patient 
becomes drowsy and dies comatose. 

Causes. — Chronic disease of the kidney, aggravated by exposure 
wet and cold. The action of certain poisons, as digitalis, arsenic, corrosive 
sublimate, and cantharides. Acute inflammation of the kidney. Mecha 
nical obstruction in the ureters. The infectious fevers. 

Diagnosis. — From retention of urine by the empty state of the 
bladder as ascertained by the hand, or the catheter. 

Prognosis. — Unfavourable in chronic disease of the kidney ; more 
favourable when it occurs in acute disease. 

Treatment. — Indications. I. Promote the elimination of urea by 
copious purging and diaphoresis; gr. i of elaterium, or Vf]ii of croton 
oil should be given immediately, and the patient exposed to a hot-air 
bath. The function of the kidney may be aroused by the injection of 
the g^th of a grain of atropia beneath the skin. 

II. If acute nephritis be present, Jx or Jxx of blood may be taken 
from the arm, or the loins may be cupped or leeched, and hot stimu- 
lating fomentations subsequently applied. 

When other means fail, powerful diuretics, such as cantharides and 
turpentine, may be administered. 

III. The head symptoms must be treated by blisters to the forehead 
and nape, and if the head be hot by a bladder of ice to the vertex. 



DIABETES— IMMODERATE FLOW OF SACCHARINE URINE. 

Symptoms. — That which first attracts attention is frequent micturi- 
tion. The urine is excessive in quantity, of a pale straw colour, of a 
peculiar faint odour resembling hay, has a sweet taste, and contains 
more or less sugar. There is inordinate appetite, excessive thirst, and 
constipation, the stools being dry and hard. The tongue is clammy, and 
red at the edge, or clean, or white with a brown streak down the 
middle ; the gums are red and tender ; the throat dry ; the breath has 
often a sweetish odour, like that of hay ; and the skin is dry and harsh. 
The patient is weak, and loses flesh ; and becomes anxious, sad, and 
irritable. After the disease has continued for some months, or even for 
several years, the symptoms continuing to increase, the emaciation be- 
comes extreme, and the patient either dies of exhaustion or phthisis. 

In some cases the sugar disappears from the urine and reappears 
after a variable interval. Sugar is frequently present in small quantity 
in the urine of old people, without producing injurious effects. 

Pathology. — M. Bernard has demonstrated the following facts : — 
I. That in a recently killed animal, sugar invariably exists in the 



DIABETES. 557 

blood of the hepatic veins, and is absent from that of the portal 
veins. II. A substance (glycogen) may be artificially separated from 
the liver, which under the influence of saliva, pancreatic fluid, blood, 
liver tissue, &c, gives the reactions of grape sugar. III. Glycogen is 
formed with equal facility and abundance when the food consists of 
nitrogenized matters only, saccharine or starchy articles of diet being 
unnecessary for its production. 

From these facts Bernard infers that sugar is formed in the liver 
during healthy assimilation ; that it passes out of it into the blood of 
the hepatic veins ; and is carried to the lungs, where it undergoes oxi- 
dation and conversion into carbonic acid and water, eliminated as such 
from the lungs. 

According to this theory, the liver and lungs have a reciprocity of 
function in the generation and destruction of sugar ; and the most 
obvious explanation of the appearance of sugar in the urine is, that 
the reciprocal actions of these two great glands become disproportionate 
the one to the other. Thus, under certain abnormal conditions, the 
liver may generate a larger amount of sugar than could be destroyed 
in a single circulation through the lungs, and sugar enters the general 
circulation, and is separated by the kidneys. Again, when only a 
normal quantity of sugar is separated by the liver, disease or functional 
derangement of the lungs may render these organs inadequate to per- 
form their sugar-destroying function, and thus also the saccharine 
matter would pass into the general circulation. 

But according to Dr. Pavy, glycogen is not normally converted into 
sugar in the liver. He supposes that it ought to be converted into 
fat, and that it is only when the function of the liver is disturbed as 
in diabetes, that it undergoes metamorphosis into sugar. He believes 
that this metamorphosis is the result of changes which commence im- 
mediately after the death of the animal. He bases this conclusion upon 
a frequently repeated observation, that the blood of the right side of 
the heart of a living animal contains only that trace of sugar which can 
be found in the left side of the heart. It appears, then, that we must 
look on the generation of sugar in the liver as a result of derangement 
or perversion of its function. Amongst the causes of this specific 
derangement are irritations of the pneumogastric nerve and brain. 
Thus Dr. Bernard induced diabetes by irritating the pneumogastric 
nerve at its origin in the floor of the fourth ventricle ; and Dr. George 
Harley by the irritation of the peripheral branches of the same nerve. 
Dr. Goolden observed that diabetes was a frequent result of blows on 
the head ; and we have had several opportunities of convincing our- 
selves of the accuracy of his observations. 

Morbid Anatomy. — The kidneys vascular and hypertrophied ; oc- 
casionally presenting granular degeneration. Tubercular deposit in the 
lungs ; shrunken condition of the brain. 

Complications and Secondary Disorders. — Pulmonary phthisis 
(the most common complication) ; granular degeneration of the kidney ; 
peritoneal inflammation ; anasarca ; apoplexy. 



558 DIABETES. 

Prognosis. — Favourable. The intermittent form of the disease ; 
a short previous duration ; urine not exceeding 12 pints in quantity 
and 1036 in density ; the emaciation not considerable ; the appetite and 
thirst not inordinate ; the skin still soft and moist ; and the mind not 
much depressed. When the patient is under treatment, the signs of 
improvement are, a decrease in the quantity of the urine, without in- 
crease of density, steady diminution in the quantity of solids discharged, 
increase of weight, strength, and activity, diminished appetite and thirst, 
the mind becoming clearer and more cheerful. — Unfavourable. Pro- 
longed duration of the disease, great emaciation, and rapid diminution 
of strength ; the supervention of pulmonary or renal disease, great and 
sudden prostration of strength. 

Causes. — Predisposing. Hereditary tendency. — Exciting. Intem- 
perance ; abuse of the sexual function ; injuries of the head. 

Diagnosis. — Excessive diuresis ; 8 gallons of urine are sometimes 
voided in the 24 hours ; 2 gallons is about the quantity usually ex- 
creted. The specific gravity is very high, ranging between 1030 and 
1070. It is sweet to the taste, and after evaporation leaves a white 
powder or sticky residue — sugar. The quantity of this substance passed 
in the 24 hours varies from half a pound to three pounds. For the 
mode of detecting sugar in the urine, and of ascertaining its quantity, 
see p. 132. 

Treatment. — I. The diet should consist chiefly of animal food, 
broiled or roasted, with a small quantity of stale and well-fermented 
bread; and liquids in moderate quantity: of which, the best are weak 
beef or mutton tea, milk, pure spring water, or water holding calcareous 
salts in solution. Gluten and bran bread may be substituted with 
advantage for common bread. The liver indeed readily converts albu- 
minous substances into sugar ; but when the diet is restricted to azotized 
food, the sugar decreases. 

II. The quantity of liquid must be limited, and the use of spirituous 
liquoi s, saline aperients, and all articles of diet or medicine which have 
diuretic properties, avoided. The secretion of the skin may be assisted 
by warm baths, friction, and warm clothing ; by opium in small and 
repeated doses, as five grains of Dover's powder three times a day. 

III. The intense thirst is best relieved by iced water acidulated with 
phosphoric acid. Claret is a suitable drink. 

IV. The strength must be supported, and the disease kept in check 
by the administration of Tr\xx-TT\xl tincturae ferri perchloridi twice 
or thrice a day : and a full dose of opium at bedtime every other night. 
Constipation should be relieved by resinous purgatives ; and debility, 
when extreme, by tonics and stimulants. 

In one case that was under my care, a young female continued for 
months to pass large quantities of saccharine urine without losing flesh 
or suffering in health. She took no medicine, except a simple tonic 
infusion, and continued, though not very strictly, a diet containing an 
excess of animal food. It is evident that no part of the sugar was 



CHYLOUS URINE — DIURESIS. 559 

formed at the expense of the structures of the body. So long as a 
patient does not lose flesh, it is probably inexpedient to adopt any 
other treatment. (G.) 

CHYLOUS URINE. 

Symptoms. — The passage of opalescent or milk-like urine. Some- 
times it has a faint pink tinge from the presence of blood. Occasionally 
the urine coagulates in the bladder and gives rise to retention. Other- 
wise the symptoms are very slight. In aggravated cases, debility, loss 
of flesh, and pain in the loins constitute the general symptoms. 

The urine is generally abundant, of a milky appearance, and varying 
in density from 1010 to 1020. After its discharge it sometimes coa- 
gulates into a white gelatinous substance, like blanc-mange, taking 
the form of the containing vessel. It more frequently retains the 
fluid condition, and separates after some time into a clear yellowish 
fluid and a white clot ; at other times a white flaky matter is de- 
posited ; or a white cream rises to the surface. The opalescence is dne 
to fatty matter in the molecular condition ; small granular cells re- 
sembling chyle corpuscles, and sometimes a few red blood corpuscles 
are also observed. On analysis, the urine furnishes, in addition to its 
normal constituents, fat and albuminous matter. 

The disease is rare in temperate regions ; but prevails endemically in 
the East and West Indies, Brazil, the Mauritius, and Bourbon. 

Treatment. — Does not admit of removal ; but it may be palliated 
by gallic acid, and the astringent chalybeates. 

Pathology. — Dr. H. V. Carter (Trans. Med. and Physl. Soc, Bom- 
bay, 1861) concludes that the chyle, by rupture of the walls of dilated 
lymphatic vessels, obtains direct entrance into some part of the urinary 
passages. In three of his cases there was an accumulation of milky 
chyle in the enlarged inguinal glands. A very close connection ap- 
pears to exist between haematuria and chylous mine. The diseases 
frequently coexist (Rayer), and Dr. Priestley relates a case (" Med. 
Times and Gaz.," April 18, 1857), in which the chylous urine was 
associated with hematuria in a native of the Cape of Good Hope. 
Further, hematuria and chylous urine are both endemic, and loth 
prevail in the same localities. From what we know of parasitic haema- 
turia (pp. 552, et seq.), it may therefore be inferred that in many cases 
at least of chylous urine, the communication between the lacteal and 
urinary channels is effected by the burrowing of parasites. In the last- 
mentioned case Bilharzia was probably the cause of communication. 

DIURESIS — IMMODERATE FLOW OF URINE. 

The passage of large quantities of wateiy urine is a direct result ot 
the excessive use of fluids, especially of spirituous liquors. It also 
occurs during functional irritation of the kidney, at the end of the 
hysterical fit, and after other mental agitation. 

The term chronic diuresis is used by Dr. Watson to designate the 



560 ACUTE AND CHRONIC CYSTITIS. 

condition which has been confusedly named Diabetes insipidus. The 
disease, or rather symptom of disease, consists in the excretion of large 
quantities of urine only differing from that of health in containing 
more water, or more or less urea than normal. These variations have 
been significantly termed by Dr. Willis, hydruria, azoturia, and 
anazoturia, respectively. When the urea is in excess the specific 
gravity of the urine is unusually high. In the other varieties it is 
exceedingly low. The diuresis is commonly associated with thirst, and 
some disorder of the digestion. 

The treatment must be directed to the regulation of the cutaneous 
and gastric functions. 



DISEASES OF THE BLADDER. 

Cystitis .... Inflammation of the Bladder. 
Enuresis • . . Incontinence of Urine . 
Dvsuria .... Difficulty in voiding the Urine. 

CYSTITIS— INFLAMMATION OF THE BLADDER. 

1. ACUTE CYSTITIS. 

Symptoms. — Pyrexia; acute pain, swelling, and tension in the 
region of the bladder; pain and soreness, increased upon pressure 
above the pubes, or in the perineum ; frequent micturition ; painful 
discharge of urine, in small quantities, or complete obstruction to its 
passage; tenesmus; vomiting. 

Causes. — Mechanical injury; falls on the abdomen when the 
bladder is distended ; local irritation by calculi ; gonorrheal inflam- 
mation extending along the urethra ; spasmodic or permanent stricture ; 
all the usual causes of inflammation ; cantharides ; stimulant urethral 
injections ; cold (catarrhus vesicce). 

Treatment. — Leeches to the perineum, followed by a hot bath 
and fomentations, a brisk saline purgative combined with a full dose of 
opium. 

The condition of the urine must be carefully determined. If it be 
hyperacid, alkalies ; if alkaline, acids, with opium, should be given. 

2. CHRONIC CYSTITIS— CYSTORRHCEA. 

Symptoms. — The discharge of an increased quantity of mucus with 
the urine, with slight symptoms of inflammation of the bladder. 

Causes. — Diseases of the prostate gland, urethra, ureters, or kid- 
ney. Stone in the bladder. Ulceration or fungus of the organ. Re- 
tention of the urine in cases of paralysis due to spinal disease. 
Obstruction to the flow of urine out of the bladder. 

If the urine remain long in the bladder it undergoes decomposition ; 
the urea assimilates four equivalents of water, and is converted into 



INCONTINENCE OF URINE. 561 

carbonate of ammonia, which sets up chronic inflammation, and the 
urine becomes bloody, and highly offensive. 

Prognosis. — 'Unfavourable in the aged and intemperate, especially 
when associated with paralysis, or renal disease. 

Treatment. — In simple cystorrhcea the use of uva ursi, bucco, 
pareira, cubebs, copaiba, black pepper, combined with mineral acids. 
The irritability of the bladder is relieved by emollient injections, such 
as decoction of marsh-mallows with laudanum, and by hot fomentations. 
The feet should be kept warm, and the patient ought to be protected 
against cold. 

If the urine be ammoniacal, bloody, offensive, and loaded with 
mucus, the bladder should be frequently washed out by means of the 
double-channeled catheter, with warm water slightly acidulated with 
hydrochloric or nitric acid. In cases of paralysis, the urine should be 
drawn off at least twice a day. 



ENURESIS— INCONTINENCE OF URINE. 

Incontinence of urine may arise from mechanical causes, or from 
functional derangements of the bladder. The latter class alone comes 
within the province of the physician. 

Causes. — Incontinence of urine, without organic defect, may arise 
from one of two causes : from violent contraction of the bladder, the 
sphincter possessing its usual power ; or from relaxation of the sphincter, 
the bladder retaining its normal contractile power. In the first case, 
there is generally some source of irritation within the bladder itself, 
the urine being hyperacid or containing acicular crystals of uric acid ; 
but in rare instances the muscular fibres are thrown into a state of 
spasm without obvious cause. The first form of disease is most common 
in males ; the second in females and children. 

Treatment. — In incontinence arising from spasm of the bladder, 
the most effectual remedies, in the absence of gravel, are narcotics or 
sedatives, administered by the mouth, or introduced into the rectum, 
in the form of suppository or enema. A grain of solid opium as a 
suppository, or half a drachm of laudanum in a starch injection, will 
generally succeed in relieving the spasm. If lithiasis be the cause of 
the incontinence the remedies appropriate for that condition must be 
employed. (See p. 552.) 

In incontinence arising from debility of the sphincter, two or three 
drops of tincture of cantharides, with ten drops of tincture of hyoscy- 
amus, increased gradually and cautiously, rarely fail of removing the 
disease. I have had several cases of this kind, which have received 
immediate benefit and a speedy cure from this mode of treatment. In 

2 



562 DYSURIA. 

one case, occurring in a young adult, after cantharides had failed, 
tinctura ferri perchloridi in the dose of 3ss three times a day effected 
a speedy cure. (G.) 

In many cases the urine is perfectly retained during the day, and 
voided only at night. These will require the same treatment. 



DYSURIA— DIFFICULTY IN VOIDING THE URINE. 

Dysuria may exist in every degree, from slight and momentary arrest 
of the flow of urine, with or without pain, to complete retention. 
Some degree of pain generally attends the abortive attempts to discharge 
the urine, and in severe cases the suffeiing is intense. 

Causes. — Long retention or acidity of the urine ; irritation or in- 
flammation of the coats of the bladder. Gonorrhoea inflamed prostate, 
gravel, urinary calculus, cystitis and nephritis, inflamed haemorrhoids, 
inflammation or irritation of the rectum, uterine affections, pregnancy, 
&c. Strangury, an aggravated form of dysuria, is produced by cantha- 
rides and other strong irritants. Dysuria is also a symptom of hysteria, 
and may occur in nervous persons of both sexes. The mechanical 
causes are stone in the bladder, stricture of the urethra, abscesses in 
the perineum, prostatic tumours, displacements of the uterus. 

Treatment. — This must depend on the cause. Of those external 
to the bladder, constipation is the most common ; and a brisk purgative, 
or a proper course of aperients, will soon i emove the disease. 

Spa ; m of the muscular coat requires the use of the warm bath with 
opiate suppositoi ies or enemata. When the spasm is of frequent occur- 
rence, tincture of the muriate of iron in repeated doses. 

When the urine is scanty and acid, alkaline diuretics, and diluents 
will be required. Dysuria following long retention of urine is best 
relieved by the warm bath. 



C 563 ) 



CHAPTEE VI. 



DISEASES OF THE ORGANS OF GENERATION. 



Amenorrhea. 

Dysmenorrhea. 

Menorrhagia. 

Leucorrhcea. 

Metritis. 

Ulceration oe the os and 

cervix uteri. 
Cancer of the Uterus. 
Fibrous tumours oe the 

uterus. 



Pelvic Hematocele. 
Displacements of the 

uterus. 
Oophoritis. 
Ovarian Tumours. 
Gonorrhea. 
Syphilis. 
Spermatorrhea. 



AMENORRHEA— ABSENCE OF MENSTRUAL DISCHARGE. 

Species. — 1. Amenorrhoea from organic deficiency. 2. Amenorrhea 
from functional derangement. 

1. ORGANIC AMENORRHOEA. 

Causes. — Absence of the ovaries ; disease or defective development 
of the ovaries ; absence or defective development of the uterus or 
vagina. Treatment, with a view to the establishment of the function, 
is of course useless in such cases, 



2. FUNCTIONAL AMENORRHCEA. 

Varieties. — (a.) Primary suppressed menstruation. (6.) Amenor- 
' rhcea with plethora, (c.) Amenorrhoea with anaemia or chlorosis. 

(a.) primary suppressed menstruation. 

The age at which menstruation begins is very variable. In this 
country the discharge may appear as early as the tenth year, or as late 
as the twentieth. In the greater number of young women it comes on 
between the ages of fifteen and sixteen. 

The discharge is preceded in most ca^es by the following symptoms : 
A little languor, flushing of the face, throbbing headache, and aching 
pain in the loins. In some cases these symptoms are attended with 
well-marked pyrexia. After a few hours an oozing of* thin non-coagu- 



564 AMEXORRHCEA WITH AX^MIA OR CHLOROSIS. 

lable dark-coloured blood of acid reaction appears. It continues for a 
variable period, usually three or four days, and then ceases, the whole 
quantity discharged being usually about six ounces. 

In many cases the menstrual nisus occurs and recurs with increasing 
severity every month without any appearance of the sanguineous dis- 
charge. Such are cases of primary suppressed menstruation. 

Treatment. — When the above-mentioned symptoms come on, a 
brisk aloetic purge, followed by Form. 295, and a hot hip-bath. 
Strict attention must be paid to the general health in the intervals. 
Moderate exercise should be taken. Fatigue and exposure to cold and 
wet must be avoided. 

In the chronic form the menstrual nisus is absent, and the general 
health is delicate. In such cases we may give chalybeate tonics, com- 
bined with stimulants, to improve the general health, and at suitable 
periods we may endeavour to elicit the menstrual flow by the exhibition 
of emmenagogues. (Form. 318.) If these fail, we may try electricity. 
The best emmenagogues are the remedies and modes of treatment which 
tend to restore the health and strength of the patient. 

(6.) AMEXORRHCEA WITH PLETHORA. 

The general symptoms and constitutional treatment are those of 
plethora. (See p. 257.) When blood is abstracted, it should be taken 
away at the approach of the menstrual period. 

(C.) AMEXORRHCEA WITH AX^MIA OR CHLOROSIS. 

For a description of the constitutional symptoms and treatment of 
anaemia and chlorosis, see p. 258, et seq. Amenorrhoea is often the 
first symptom of anaemia and chlorosis ; or it may make its appearance 
after these states have existed for a considerable period. 

In addition to the general treatment of anaemia, it is sometimes 
necessary to prescribe the measures for the restoration of the menstrual 
discharge mentioned under the first variety of the disorder. 

Amenorrhoea is sometimes accompanied by vicarious or supplemental 
discharges of blood, or of blood slightly altered from its usual character, 
from the nose, lungs, stomach, or rectum, and from ulcers of the skin. 
These discharges, if occurring in important organs of the economy, may 
require medical interference, and are best treated by leeching and purg- 
ing, practised a little before they are expected. 

The catamenia are normally absent during gestation and lactation. 
Some women, however, menstruate during pregnancy only. With 
others, the flow occurs at the regular periods during the process of 
lactation. 

The complications of amenorrhoea, which are extremely numerous, 
must be treated by remedies appropriate to those complications, com- 
bined with such as restore strength to the system, and tend to re- 
setablish the menstrual discharge. 



( 565 ) 



DYSMENORRHEA— PAINFUL MENSTRUATION. 

Symptoms. — Pain in the loins preceding the menstrual period by a 
few hours or days ; tenderness in the hypogastric region, and some- 
times over a considerable extent of the abdomen ; soreness or acute 
darting pains, resembling those of colic, and occurring mostly in 
paroxysms ; vomiting ; diarrhoea with tenesmus ; dysuria. Hysteria 
is often present. These symptoms increase in severity until the appear- 
ance of the catamenia, and then cease suddenly or gradually. Severe 
cramp, with rigors and coldness of the surface, almost amounting to 
collapse, precede the flow in some cases. The discharge is often scanty, 
and is sometimes accompanied by a membranous formation moulded to 
the internal surface of the uterus. 

Causes. — Predisposing, The rheumatic diathesis ; the nervous 
temperament. — Exciting. Sudden and violent emotions ; increased 
determination of blood to the uterus; sexual intercourse immediately 
before the expected flux ; constipation ; spinal irritation ; exposure to 
cold ; mechanical obstruction from organic or spasmodic constriction of 
the cervical canal, or from retroflexion of the uterus. 

Prognosis. — Favourable. Most cases admit of cure, or relief, by 
the improvement of the health, and proper local treatment. 

Treatment. — I. When there is plethora, the application of leeches 
to the vulva, or cupping-glasses to the loins ; tepid, hot, or vapour 
baths ; opium alone, or with small doses of tartarized antimony fre- 
quently repeated. 

II. Careful attention to the functions of the stomach and bowels, 
moderate depletion to meet any irregular determination of blood, and 
strict attention to the general health. 

Organic impediments must be removed if possible. Stricture of the 
cervical canal may be relieved by graduated bougies carefully intro- 
duced. Those made of the fucus Laminaria are very serviceable. 



MENORRHAGIA— EXCESSIVE MENSTRUATION. 

The menstrual flux is excessive, when the intervals are less than 
three weeks, continues longer than six days, and is abundant during 
the whole of this time. It may be the effect of two opposite states of 
the system : — plethora (active m.) ; and general relaxation or debility 
{passive m.). 

Symptoms. — Menorrhagia, arising from plethora, is usually preceded 
by acute pains in the head and loins, a sense of heat, fulness and 
throbbing in the pelvis, turgid flushed countenance, universal heat, 
and a strong, hard pulse: when, on the contrary, the symptoms of 
debility prevail, the pulse is small and feeble, the face pallid ; there is 



566 VAGINAL LEUCORRHCEA. 

dull aching pain in the back and loins, and in nervous persons the 
group of nervous symptoms described under Mimosis Inquieta. (S 
p. 264.) 

Causes. — Predisposing. Plethora ; laxity of the womb from fre- 
quent parturition; displacement of the uterus; difficult and tedious 
labours, or repeated miscarriages ; a sedentary and inactive life ; heated 
apartments, and all causes of debility. — Exciting. Violent exercise ; 
blows or concussions ; violent straining at stool ; tight lacing ; sexnal 
excess, particularly during menstruation ; exposure to wet and cold ; 
congestion or ulceration of the mucous membrane ; uterine tumours. 
Attacks of monorrhagia are common in women at or shortly after the 
change of life. 

Prognosis. — Favourable, if it be not of very long standing, or de- 
pendent upon organic disease. 

Treatment. — The treatment of menorrhagia consists in — 

1. Reducing the febrile symptoms and the plethoric condition of the 
pelvic circulation by fee purgation, gr. x of colocynth and blue pill, 
followed by a saline (Form. 264) with TTl xx tincture of henbane. 

2. When the febrile symptoms are subdued, astringent remedies 
(Form. 167). 

If the haemorrhage be profuse, cold water should be injected into 
the rectum and vagina. If this does not suffice, injections of alum or 
tannic acid must be used, and, if need be, the vagina must be plugged 
w T ith sponges saturated with such solutions. 

The patient should keep the horizontal posture on a hard mattress. 
The clothing should be light and the regimen cooling. 

3. When symptoms of debility are present, tonics or stimulants, in 
combination with sedatives, are required. 



LEUCORRHCEA— THE WHITES. 

Definition. — Discharge of a milk-white or glairy mucous fluid 
from the orifice of the vagina. 

Varieties. — 1. Vaginal. 2. Uterine. 

1. YAGINAL LEUCORRHCEA — VAGINITIS. 

Symptoms. — Pain and soreness, with heat and fulness of the vagina ; 
vesical and urethral irritation, resulting in frequent micturition, pain, 
and dysuria ; soreness and itching of the vulva ; a thin colourless acid 
discharge becoming, in the chronic form of the disease, more or less 
creamy or purulent. The vagina is swollen and tender, and the 
mucous membrane, which is naturally of a pale rose tint, is uniformly 
dark red, and inflamed. This is an uncommon form of the disease. 



UTERINE LEUCORRHCEA. 567 

Diagnosis. — There are no characters by which simple vaginitis may 
be distinguished from the gonorrheal variety. The character, of the 
patient and of her husband, if she be married, must decide the diagnosis. 
Some observers are of opinion that simple leneorrhcea may, by contact, 
induce both urethral discharge and preputial sores in the male. From 
the uteiine variety, it is distinguished by the absence of inflammation 
of, and discharge from, the os uteii, by the thinner and more acid 
nature of the discharge, and by the circumstance that vaginal leucorrhcea 
is not increased before or after the time of menstruation. There is 
also an absence of uterine symptoms, and the health suffers less. 

Causes. — Simple vaginitis usually results from direct irritation: 
e. g, pessaries in the vagina ; violence in sexual intercourse ; irritation 
of the rectum from piles or ascarides. It is often associated with ex- 
cessive acidity of the urine. 

Treatment. — General, saline alkaline aperients, and the hip-bath. — 
Local, the removal of any sources of irritation which may be present ; 
warm-water injections, and afterwards the injection of an astringent. 
(Form. 182, l8y.) 

In the chronic form the most scrupulous cleanliness is required. 
Zinc or alum injections should be used twice a day; quinine or the 
astringent chalybeates should be prescribed. 

2. UTERINE LEUCORRHCEA INFLAMMATION OF THE OS AND 

CERVIX UTERI. 

Symptoms. — The discharge of an inodorous white creamy fluid vary- 
ing in quantity from a slight increase of the natural secretion to several 
ounces in the day, increased largely immediately before and after men- 
struation, and sometimes taking its place. Pain and weakness of the 
loins, excessive debility, and a sense of bearing-down in the pelvis ; the 
vagina is relaxed, and the os uteri lower down than normal ; the cervix 
uteri is swollen, and the os red, congested, patulous, and occupied by a 
glairy secretion like white of egg. As this passes down the vagina, it 
becomes altered by its acid secretion into a creamy fluid. The general 
health suffers in a marked degree: the appetite is lost or impaired; the 
bowels are constipated, or irritable; and spinal irritation aie often pre- 
sent, and the symptoms described under Mimosis Inquieta (p. 264). 

Causes. — Inflammation of the os and cervix uteri ; the discharge is 
derived from the extensive glandular surface which Dr. Tyler Smith 
has shown to line the canal of the cervix uteri. Debility, suppressed 
menstruation, abortion, frequent parturition, lactation and congestion 
of the cervix uteri, all predispose to this condition. 

Treatment. — I. Must be directed to improve the general health 
by the judicious use of saline aperients and tonics, moderate exercise, 
rest of the sexual organs, cold bathing, and, if need be, change of air. 
II. The local treatment will consist in the use of cold water or astrin- 
gent injections (Form. 191). When much irritability is present, 



568 ACUTE AND CHRONIC METRITIS. 

opiate injections may be required ; and if there be much congestion, or 
if there be signs of local inflammation, a few leeches may be applied to 
the neck of the uterus. 

The remedies which act on the mucous membrane through the 
general system are given in the Formulae. 



METRITIS— INFLAMMATION OF THE UNIMPREGNATED 

UTERUS. 

1. ACUTE METRITIS. 






Symptoms. — Pain, increased by pressure, in the region of the uterus, 
and in the cervix on examination per vaginam ; pain extending to the 
loins and thighs; dysuria; a sense of weight and bearing down; 
swelling of the abdomen and tympanites. These local symptoms are 
generally accompanied by fever, with nausea and vomiting. In the 
most severe cases, there are slight delirium, drowsiness, extreme pro- 
stration of strength, diarrhoea, and subsultus tendinum. At first there 
is no vaginal discharge, but after a day or two, an abundant and often 
offensive purulent, or muco-purulent discharge, occasionally tinged 
with blood, appears. The uterus is slightly enlarged, and very tender 
to the touch, and the arteries of the cervix pulsate strongly. 

Morbid Anatomy. — The substance of the uterus inflamed and en- 
larged, cedematous, and softened : in severe cases, pus is infiltrated 
through its tissue ; or an abscess is formed in it. Purulent matter may 
also be found in the veins in the pelvic cellular tissue, and in the folds 
of the broad ligament. Swelling and redness of the mucous membrane. 

Causes. — Predisposing. Those of inflammation generally. — Excit- 
ing. Suppression of the menstrual discharge from cold ; the use of 
astringent injections; frequent sexual intercourse; extension of gonor- 
rhoeal inflammation ; physical injuries ; blows and falls ; childbirth. 

Treatment. — Leeches to the vulva or groins ; a free saline aperient 
followed by calomel and opium (Form. 329), hot fomentations, turpen- 
tine stupes, or sinapisms, a hot hip-bath. Dysuria may be relieved by 
mucilaginous drinks, and the bowels should be kept free by gentle saline 
aperients, or by castor-oil. 

2. chronic metritis. 

This is a common consequence of the acute form, when neglected or 
badly treated. It may assume a variety of shapes, and lead to a great 
number of severe structural lesions of the uterus, such as ulceration, 
suppuration, membranous inflammation, and enlargement and indura- 
tion of the mucous follicles and muscular structure of the organ. 



( 569 ) 
ULCERATION OF THE OS AND CERVIX UTERI. 

1. SIMPLE ULCERATION. 

Symptoms. — Uterine leucorrhcea, occasionally tinged or streaked 
with blood ; pricking, darting, or throbbing pain in the situation of the 
os uteri ; great irritability of the bladder ; a sense of bearing down. 
Action of the bowels, sitting, and sexual intercourse produce pain. It 
is also increased immediately before the appearance of the catamenia, 
and is usually absent for a short time afterwards. The menses are un- 
usually profuse. 

The os uteri is low down, swollen, and tender, and the hard and 
painful glandular tissue can be felt through the mucous covering. The 
cervix is enlarged, congested, and presents superficial ulceration on one 
or other side of the os, of variable extent. The ulcerations are depressed, 
and usually present healthy granulations. In chronic cases the granu- 
lations are angry-looking, and the edges of the ulcer thickened. 

Treatment. — The general treatment will be the same as that for 
inflammation of the os and cervix uteri. (See Uterine Leucorrhcea.) 

The local treatment consists in the use of mild zinc injections, and 
the repeated applications of nitrate of silver, solid, or as in Form. 182. 
When the cervix is within the patient's reach she may occasionally 
apply the Unguentum hydrargyri nitratis. 

2. CORRODING ULCERATION. 

Symptoms. — Pain and weakness in the loins ; more or less localized 
pelvic pain and uneasiness, sometimes of an acute burning or catting 
nature ; the passage of hardened fasces gives pain ; at first there is leu- 
corrhcea, subsequently a thin watery yellowish discharge, occasionally 
tinged with blood ; as the ulceration spreads, attacks of profuse haemor- 
rhage, which sometimes recur so often as to endanger the life of the 
patient. The finger detects a loss of substance ; the cervix is shorter 
or altogether absorbed, but the eroded surface is soft and rarely very 
uneven ; there is no induration about the edges or base of the ulcer, the 
whole surface of which has a pulpy feel. Pressure with the tip of the 
finger does not produce pain, but merely a sensation of soreness. The 
ulcer has a ragged excavated appearance, and is covered with ashy-grey 
debris ; when this is removed a raw bleeding surface is exposed. In 
severe cases the ulceration extends to the contiguous parts of the vagina. 
The fundus of the uterus is unaffected, and easily moved. 

The patient becomes anaemic and excessively debilitated from the re- 
peated hsemorrhage due to the erosion of blood-vessels in the extension 
of the disease ; and if the disease be not speedily checked she dies of 
asthenia. 

Diagnosis. — From cancerous ulc r ration by the absence of induration, 
of acute pain on pressure, and of paroxysms of darting pelvic pain, by 
the mobility of the uterus and the limitation of the disease. 



570 MEDULLARY CANCER. 



e early, 



Prognosis. — Unfavourable. But if we can treat the disease 
we may arrest, and in some cases cure it. 

Treatment. — Must be directed to improve the health by astringent 
tonics and nutritious food. To check the erosion by the application of 
strong nitric acid, the acid nitrate of mercury, nitrate of silver, and the 
actual cautery. The most efficacious is the actual cautery. When the 
eschar separates the caustic should be again applied if the surface does 
not present a granular appearance. When healthy granulations appear, 
we may expect a permanent cure. The vagina should be frequently 
injected with astringent lotions. 



CANCER OF THE UTERUS. 
Species. — 1. Medullary. 2. Epithelioma (cauliflower excrescence). 

MEDULLARY CANCER. 

Symptoms. — Deep-seated pains in the pelvis coming on in paroxysms 
and readily induced by evacuation of the bowels or bladder, the recur- 
rence of the menstrual period, or sexual intercourse. The paroxysms 
gradually lengthen, the pain assumes a sharp neuralgic or lancinating 
character, and the menstruation becomes irregular. Menorrhagia is an 
early and prominent symptom. There is a sense of weight and fulness 
in the pelvis. The cervix is enlarged and hard, the os uteri patulous, 
and its margins hard and deeply notched ; pressure produces acute pain ; 
the body of the uterus is enlarged, and has lost much of its mobility. 
The os and cervix appear swollen, tense, and of a mottled red, or 
purplish colour ; in many cases the mucous membrane retains its natural 
appearance. The indurated tissue soon begins to ulcerate and break 
down, and a watery, greenish, very foetid discharge, occasionally tinged 
with blood, appears ; and haemorrhage now very frequently recurs. 
The enlarged cervix becomes soft and ragged, and the finger may be 
readily passed into the uterus, the walls of which feel partly pulpy and 
partly nodular. The fundus is now firmly fixed in a solid mass which 
surrounds it. The degeneration and ulceration slowly extend back- 
wards, involving the rectum ; or forwards, implicating the bladder. 
The walls of both of these cavities are sometimes destroyed, and the 
contents mingle in the vagina with the uterine discharges, and are in 
part evacuated through the vulva. The health rapidly declines, the 
stomach sympathises and food is rejected, the cachexia and emaciation 
are extreme, and the patient dies, worn out by the excruciating pain 
and excessive discharges. 

Diagnosis. — Haemorrhage, and in the intervals a watery foetid dis- 
charge ; deep-seated paroxysms of lancinating pain ; indurated enlarge- 
ment of the os and cervix uteri ; immobility of the fundus ; emaciation 
and a sallow cachectic appearance are positive indications of the cancerous 
nature of the disease. 



FIBROUS TUMOURS OF THE UTERUS. 571 

Treatment. — In the early stage when the deposit is limited to the 
vaginal portion of the cervix, the removal of this portion by means of 
the e'craseur. Later on the treatment must be palliative only — the 
application of caustics does harm. The general treatment will consist 
in the exhibition of chalybeate tonics, of iodide and bromide of potassium, 
combined with tonic infusions. The pain and irritability of the stomach 
may be relieved by alkalies in a state of effervescence, combined with 
hydrocyanic acid. When the stomach will bear it, cod-liver oil may be 
given to counteract the emaciation. The strength should be sustained 
by wine and light nutritious diet administered frequently, in small 
quantities. Sleep must be procured, and the uterine pain alleviated by 
occasional doses of opium. Opiate suppositories and injections may be 
employed with the same view. The vagina must be frequently washed 
out with warm water, to which a little carbolic acid has been added, to 
destroy the fcetor of the discharges. When disease opens the rectum or 
bladder, the most scrupulous attention to cleanliness will be required. 

2. EPITHELIOMA (CAULIFLOWER EXCRESCENCE). 

Symptoms. — A copious watery discharge, occasionally streaked with 
blood, from the vagina; subsequently profuse florid haemorrhage, in- 
duced by sexual intercourse, straining at stool, or any other direct cause 
of congestion or irritation; a rough villous insensible mass is felt at- 
tached to the os uteri at some part of its circumference ; the tumour has 
a florid colour, and a granular or villous structure ; when handled 
freely, it bleeds. Its growth is rapid, and it sometimes attains such 
a size as to occupy the whole of the vagina and protrude between the 
labia. The disease is limited to the uterus, and if removed it is speedily 
reproduced. The patient rapidly becomes anaemic, and dies of asthenia. 

Diagnosis. — The structure and appearance of the tumour and its 
origin by a broad base from the os uteri are conclusive as to its nature. 

Treatment. — The general treatment will consist in the exhibition 
of the astringent chalybeates combined with the mineral acids ; the only 
efficient local treatment is removal of the tumour and contiguous part 
of the cervix uteri by means of the e'craseur, and the subsequent use 
of strong nitric acid, or the actual cautery, followed by astringent injec- 
tions. 



FIBROUS TUMOURS OF THE UTERUS. 

These occur, I. As interstitial growths within the muscular walls of 
the uterus. II. As isolated fibrous or fibro-cartilaginous masses de- 
veloped within the uterine walls, and projecting more or less from them. 
III. As pedunculated growths attached to the outer, or more frequently, 
to the inner surface of the uterus ( Uterine polypi). 

The first and second variety often form enormous growths from the 
uterus, sometimes weighing more than fifty pounds, and are accompanied 



572 FIBROUS TUMOURS OF THE UTERUS. 

by hypertrophy of its natural structure, with enlargement of its cavity. 
They are composed of white fibrous or of fibro-cartilaginous tissue, and 
have very little vascularity. They are of gristly, and occasionally, from 
more or less perfect ossification, of bony hardness. Their colour is 
greyish-white, and the section is pervaded by intersecting or concentric 
bands of white filnous tissue. The first variety of tumour is continuous 
with the uterine tissue ; the second, which is almost always composed 
of fibro-cartilage, is surrounded by a distinct areolar investment, which, 
by limiting it, allows of its ready separation from the contiguous uterine 
tissue. Usually there are more than one of these tumours. In pro- 
jecting outwards towards the peritoneal cavity, or inwards towards the 
mucous suiface, they sometimes become almost completely invested, 
the former case with peritoneum, in the latter with mucous membrane, 
and so come to form large pedunculated growths. Cysts are occasionally 
formed in the interior of these tumours. 

The symptoms which attend the development of the first and second 
variety are precisely similar. They are usually so obscure, that the 
tumour attains a considerable size before it attracts attention, and then 
the patient supposes she is pregnant, or the subject of dropsy. When the 
rectum or bladder are pressed upon, there will be frequent desire to 
evacuate the faeces and urine, and more or less difficulty will probably 
attend these acts. The menstrual function is sometimes interfered with, 
sometimes not. In the majority of cases the discharge is more profuse 
than usual, and it is apt to come on at irregular intervals ; occasionally 
there is dysmenorrhoea. The os and cervix uteri are felt to be natural ; 
but around and above the latter there is a hard rounded mass, filling up 
the sacral cavity. If the other hand be placed upon the lower part of 
the abdomen, a large hard nodular mass may be tilted against it by 
pressing the tumour upwards with the finger. The uterine sound 
readily passes, sometimes in one direction, sometimes in another, an un- 
usual distance within the uterine cavity, proving that it has undergone 
considerable enlargement. 

The health is unaffected so long as the pressure of the tumour does 
not produce derangement of the contiguous viscera or blood-vessels. 

Treatment. — The treatment of the first variety must be purely con- 
stitutional. With a view of reducing the tumour and preventing its 
further development, chloride of calcium, iodide or bromide of potassium, 
and the Kreuznach waters have been recommended. 

Enucleation has been proposed for the second variety ; but the opera- 
tion has been attended with so large a proportion of deaths that we deem 
it unjustifiable. When self-enucleation of the tumour has been nearly 
effected, we may facilitate its expulsion from the uterine cavity by 
dilating the os and cervix and administering ergot. 

The third variety of fibrous tumours (uterine polypi) give rise to 
much more serious symptoms. These are leucorrhoea and haemorrhage, 
which increase in severity and endanger the patient's life. At first the 
menstrual periods are protracted, then the discharge becomes more 
profuse. In the intervals there is profuse leucorrhcEa. After a time 



PELVIC HEMATOCELE. 573 

the regularity of the haemorrhage ceases, and the patient is at last rarely 
fiee from sanguineous discharge, and a constant bearing-down or drag- 
ging sensation. On examination, the os uteri is felt low down, and 
patulous, and on passing the ringer within the orifice a firm rounded 
projection mav be felt, which can only be mistaken for the inverted 
fundus. The diagnosis is readily effected by means of the uterine sound, 
which, in the case of the pedunculated tumour, proves that the cavity 
is enlarged, while in inversion of the fundus it is diminished. If the 
cervical canal be contracted it must be dilated with a sponge tent in 
order to ascertain the existence of a tumour. 

Treatment. — The only efficient treatment consists in the removal of 
the tumour. The os uteri having been dilated, the tumour must be 
seized with a hooked forceps and pulled downwards, and a ligature 
passed round the pedicle. Whenever it is practicable, the pedicle should 
be severed by the ecraseur, or blunt scissors ; for the putrefactive process 
which follows ligature without subsequent removal of the tumour, is 
very liable to set up putrid fever and endanger the patient's life. 



PELVIC HEMATOCELE. 



Synonyms. — Uterine, peri-uterine, and retro-uterine hematocele. 

Attention has of late years been called to the fact that during the 
intense vascular excitement which occurs at the menstrual periods, the 
congested vessels of the ovary or fibriated extiemity of the Fallopian 
tube may rupture and lead to effusions of considerable quantities of 
blood into the recto-uterine pouch. This accident of menstruation is 
most frequent between the ages of twenty and thirty, the period of 
greatest sexual vigour. 

Symptoms. — Usually after sudden suppression of the menstrual 
discharge, severe abdominal pain, undergoing increase at intervals, 
tenderness of the lower parts of the abdomen, difficulty and pain in 
micturition and defalcation ; usually pain in flexing one or other thigh ; 
there is increased fulness of the abdomen. The pelvic tumour differs 
much in size and situation. It usually bulges the posterior wall of 
the vagina, and tilts the body of the uterus forwards. It feels hard and 
solid. If all go on well, the pain and fever subside, and the blood 
begins to be absorbed. During the process, which is a slow one, there 
remains some difficulty in evacuating the contents of the bladder and 
rectum ; there is weight and bearing down in the pelvis, and walking 
causes pain or inconvenience. The erfused blood sometimes sets up 
pelvic inflammation, and the clot, becoming imperfectly encysted, breaks 
down into pus. The abscess may burst into the vagina, the rectum, 
bladder, intestine, or into the peritoneal cavity. 

Treatment. — At the time the haemorrhage occurs, we mav, in a 
plethoric person, take fifteen or twenty ounces of blood fiom the arm. 



574 DISPLACEMENTS OF THE UTERUS. 

In other cases half a dozen leeches should be applied around the anus. 
A full dose of opium should be given, and subsequently Form. 213, 
with a little sulphate of magnesia. 

The absorption of the bloud tumour may be facilitated by iodine in- 
flictions, and the internal administration of iodide of iron. The menstrual 
function should be regulated, and the circulation relieved, before each 
catamenial period by the administration of brisk hydragogue purgatives. 



DISPLACEMENTS OF THE UTERUS. 

The unimpregnated uterus is liable to downward, backward, and 
forward displacements, known respectively as prolapsus, retroversion, 
and anteversion. 

Prolapsus, may be partial ; or complete, when the womb pro- 
trudes entirely out of the vagina. 

Symptoms. — A sense of bearing down ; dragging pain in the loins ; 
leucorrhcea. If the uterus be displaced suddenly, acute pain ; fainting, 
and haemorrhage. 

Diagnosis. — From protruded pedunculated tumour, by the arrest of 
the uterine sound when passed aside of the tumour into the vagina. 
The finger or sound cannot be introduced beyond the prolapsed uterus, 
because the vagina is pushed down with it and inverted. The pro- 
lapsed uterus forms a pear-shaped tumour, the small end being directed 
downwards and presenting the orifice of the cervix. These characters 
distinguish it from the inverted uterus. 

Causes. — Leaving bed too soon after parturition ; debility and leu- 
corrhcea ; severe chronic cough ; straining ; injuries to the perineum. 

Treatment. — Tonics, astringent injections, and sponge pessaries, are 
usually sufficient for the relief of partial prolapse. A T bandage and 
suitable pessaries are needed in addition, when the prolapse is complete. 

Retroversion. — I. When the womb is completely displaced, the 
fundus is directed backwards against the rectum, and the os forwards 
towards the symphisis, and the organ lies horizontally across the 
pelvis. II. The position of the os and cervix may not be greatly 
altered, while the fundus is bent downwards and backwards at the 
upper part of the cervix, so as to descend as low as the os and lie in 
the recto-uterine pouch : this condition is known as retroflexion. 

Symptoms. — Sacral pain, aggravated at the menstrual periods, sense 
of dragging in the groins and down the inside of the thighs, irrita- 
bility of the bladder ; dysmenorrhcea ; monorrhagia. The os uteri is 
swollen, congested, low down, and directed more or less forwards ; 
behind it a firm round tumour can be felt through the posterior wall 
of the vagina, filling up the hollow of the sacrum and pressing on the 
rectum. On tracing the cervix upwards from the posterior lip, the 
finger comes upon the angle formed by the body and neck of the 



INFLAMMATION OF THE OYAKY. 575 

uterus. The uterine sound passes but a short way if its curve he 
directed forwards, but on rotating the handle, the instrument readily 
passes into the uterine cavity, and its point can be felt, by the ringer 
in the rectum, occupying the interior of the retroflexed fundus. 

Causes. — Predisposing. Abortion, constipation, retention of urine, 
laxity of the uterus, and of the round and broad ligaments. — Exciting. 
Straining ; a false step. 

Treatment. — Replacement with the uterine sound, after which the 
patient should lie in the prone position for some hours, and do so daily 
for a time ; astringent injections ; the bowels to be kept free ; all 
straining to be avoided. 

Anteyersiox is the rarest displacement of the uterus. 

Symptoms. — Pubic pain ; pain and irritability of the bladder ; the 
os uteri directed more or less backwards, and the fundus felt through 
the anterior wall of the vagina just behind the symphisis. When the 
os uteri is not directed much backwards, there is dysmenorrhea from 
obstruction caused by the bending of the cervix. The uterine sound 
only passes when the point is much curved forwards. 

Causes. — Predisposing. Abortion, constipation. — Exciting. Violent 
exertion ; sudden jolting, as in riding. 

Treatment. — Replacement with the uterine sound ; the supine 
posture ; purgatives ; an abdominal belt. 



OOPHORITIS— INFLAMMATION OF THE OVARY. 

Symptoms. — A dull, sickening, deep-seated pain in the groin, with 
tenderness of the iliac region. So long as the inflammation is confined 
to the ovary the pain is local, but frequently it involves the contiguous 
peritoneum, and becomes diffused over the lower part of the abdomen, 
which is swollen and tender ; the pain increases in severity, and ra- 
diates down the inside of the thigh, being increased by extension of the 
leg ; nausea and vomiting come on, and the symptoms much resemble 
simple peritonitis; but on manipulation we have no difficulty in tracing 
the pain to its source deep in one or other of the iliac fossa?. The os 
and cervix uteri are usually very painful to the touch, not from in- 
flammation of these parts, but from transmission of the pressure to the 
inflamed ovary. On passing the finger alongside of the cervix, the 
exquisitely tender ovary may be felt through the wall of the vagina, 
lying in the direction of the sacro-iliac articulation. Whether we feel 
the ovary or not, pressure in this direction causes intolerable sickening 
pain. 

Cause. — Suppression of the menses, from exposure to cold. 

Treatment. — A full dose of opium ; leeches, applied to the groins, 
anus, or, still better, to the upper part of the vagina on the painful 
side ; a hot hip-bath and a brisk purgative ; hot fomentations to the 



0<b OVARIAN DROPSY. 

abdomen. If there be signs of peritoneal inflammation, calomel and 
opium must be administered, so as slightly to affect the gums. If the 
menstrual flow can be re-established, the patient will probably do well. 
If the acute inflammation be neglected or improperly treated, the 
disease becomes chronic, and ovarian dysmenorrhea, or cystic disease 
of the ovaries, will result. 



OVARIAN TUMOURS and DROPSY. 

Ovarian tumours are almost invariably cystic growths. 

From the nature of the changes which attend the development and 
discharge of the ovum, no other organ is so liable to cystic degenera- 
tion as the ovary. Indeed all the elements of such a morbid process 
are present at every menstrual period. Hence the necessity of carefully 
regulating this important function. 

The following varieties of ovarian tumour are found to occur : — 

1. The simple cystic tumour. — The ovary being distended into a 
single cyst containing several gallons of fluid, which is usually a clear 
watery serum, but, in some cases, a thick brown grumous fluid, which, 
when heated, becomes solid. 

2. Compound ovarian cysts. — In these the proportion of solid and 
fluid constituents varies; sometimes the cysts are very large, and 
separated by thin partitions; sometimes small, and surrounded by 
thick walls of firm fibrous or vascular tissue. This latter kind has 
been named Cystosarcoma. 

3. Alveolar or colloid tumour. — In this form the enlarged ovary is 
developed into innumerable minute cells, none exceeding an inch in 
diameter, filled with a glutinous jelly-like material. 

4. Cysts containing developed tegumentary organs — teeth and hair. 

Symptoms. — Are at first obscure, and attract little or no notice; 
suppression or irregularity of the menses, is one of the earliest symp- 
toms : pain, referred to the side w r here the disease begins, is present in 
one-third of the cases ; retention of urine, or difficult micturition, in 
about one-ninth ; in one-third of the cases the tumour is discovered 
unexpectedly. (West.) It is always at first seated on one side. When 
it has attained such a size as to attract the patient's notice, there is 
pain or numbness extending down the corresponding leg, and when the 
left ovary is affected the passage of fasces may be hindered. Usually 
there is more or less complete suppression of the catamenia. 

-As the tumour grows it distends the abdomen equally, and may 
then be mistaken (if mostly solid) for the pregnant uterus, a fibrous 
tumour of that organ, or cystic disease of the kidney (see p. 549; ; if 
it be fluctuant, for ascites. 

OVARIAN DROPSY. 

The first two varieties of ovarian tumour (the monocystic and the 
polycystic) are those that give rise to ovarian dropsy. A distinction 



GONORRHOEA. O t i 

can generally be made by the extent of the fluctuation. In the case of 
the single cyst, a tap on one side of the belly produces distinct fluctua- 
tion on the other. When the cyst is compound, the partitions inter- 
rupt the fluctuation generated in any one cyst, and it can be only felt 
within its own limits. In either variety the most protuberant parts 
of the abdomen are dull on percussion, while the sides are more or less 
resonant. The belly does not swag to the sides when the patient lies 
in this position ; the upward development of the tumour causes great 
divergence of the false ribs, and if the fingers be insinuated between 
their margin and the tumour, its tense rounded outline may be felt. 

Diagnosis of Ovarian Dropsy. — From the pregnant uterus, by 
the absence of foetal sounds and movements, by the unaltered state of 
the uterus. From ascites, by the history of the case, which shows 
that the tumour commenced in the side ; the tumid abdomen sways 
from side to side according to the position of the patient ; and that its 
most prominent parts are resonant from air in the floating intestines. 
In ascites the pelvic viscera are pushed down, and the uterus is low : 
in ovarian disease, the tumour rises out of the pelvis, and drags the 
uterus a little way with it. Some cause of ascites, such as an en- 
larged nodular liver, may also be discovered. 

The distended bladder has been mistaken for ovarian dropsy. As it 
forms a symmetrical pyriform tumour, this can only occur through 
gross carelessness ; but there is some excuse for mistaking for it an 
assvmetrical multilocular bladder. I have myself seen half a pint of 
urine drawn, by the trocar and canula, through the abdominal walls. 
from a distended bladder of this description. 

Treatment. — If the tumour come under treatment early, increases, 
and is moveable, it should be extirpated forthwith. From the results 
of the operation of spaying in quadrupeds we infer how safely the re- 
moval may be effected in the early stages of the disease. When the 
tumour has attained a great size, removal should not be attempted if, 
from manipulation and the history of previous attacks of pain and 
pyrexia, we infer that the tumour is adherent. In such cases, if the 
tumour be fluid we must resort to tapping as often as the pressure 
of the tumour interferes with the respiratory or digestive functions. 
Excision of a portion of the cyst wall, and the injection of solutions of 
iodine, have been successfully employed to procure inflammatory ad- 
hesion of the cyst walls and obliteration of the cyst in those cases in 
which the tumour cannot safely be removed. 

With a view of arresting the growth of the tumour we must seek to 
improve the health of the patient by astringent tonics. 



GOXORRHCEA. 



Definition. — A specific inflammation of the genito-urinary mucous 
membrane from impure sexual connection. 

Symptoms.— In men, about seven days after contagion, a tickling sen- 



578 SYPHILIS. 

sation at the orifice of the urethra and scalding pain along the passage 
in micturition ; the orifice is red and swollen, and in the course of a few 
hours a thin discharge, quickly becoming thick, puriform, and of a yel- 
lowish-white colour, appears. The passage becomes much swollen, and 
the stream of urine is diminished. Painful erections occur, and occa- 
sionally a little bleeding takes place after micturition. The prepuce is 
usually much inflamed and swollen, giving rise to phymosis or paraphy- 
mosis. If the body of the penis be implicated in the swelling, painful 
curving of the organ (chordee) takes place during erection. In severe 
cases the inflammation extends backwards, to the seminal ducts, and 
thence along the vas deferens to the testicle ; to the bladder ; or to the 
uterus, producing severe inflammation of these parts. When orchitis 
supervenes the puriform secretion is altogether suppressed. If suppres- 
sion occur, febrile symptoms set in, and severe ophthalmia or swelling 
of the joints (cronorrhceal rheumatism) appears. 

In women the inflammation is usually confined to the vagina, and 
unless the urethra is implicated little pain or incon- 
Fig. 78. venience is experienced. When it extends to the uterus, 

symptoms of severe metritis (p. 568 J appear. 

Diagnosis. — From simple uiethritis and vaginal 
leucorrhcea, by the violence of the inflammation. 
Donne considers the presence of the ciliated animalcule 
the Trichomonas vaginalis, (Fig. 78), to be diagnostic 
of the specific vaginal inflammation; but it is formed 
with other morbid conditions of the vaginal mucus. 

Treatment. — In mild cases the administration of saline purgatives ; 
and injections of warm water followed by a mild lead or zinc injection. 
If the discharge do not cease after the pain and inflammatory symptoms 
have disappeared, copaiba or cubebs are required. 

If there be much swelling and chordee, hot fomentations and the use 
of lint soaked in the Linimentum belladonnas ; to prevent the latter con- 
dition, a grain of opium with camphor may be given. 

In many cases the discharge degenerates into a colourless glairy secre- 
tion known as gleet. This is very difficult to remove : it appears to be 
caused by a congested and relaxed condition of the mucous membrane of 
the urethra. In such cases cubebs, copaiba, and cantharides are often 
efficacious. 




SYPHILIS. 

Definition. — A specific disease, arising from contact with a pecu- 
liar animal poison. 

Symptoms. — After a period of incubation, varying from three to five 
days, the appearance of a pimple, pustule, crack, or abrasion upon the 
skin or mucous membrane of the genital organs. In the male the gians 
or the under surface of the prepuce, and in the female the inner surface 
of the labia, are the parts usually aifected. The pimple enlarges, and 



SYPHILIS. 579 

the base becomes red ; usually the summit softens down into a thin 
purulent fluid ; the cuticle gives way, and a minute excavated sore, 
destitute of granulations, is formed. The sore now enlarges, and in two 
or three days attains the dimension of a pea ; it is perfectly circular, and 
deeply and smoothly concave, being covered with a smooth ashy layer of 
sloughy tissue. The ulcer is limited by a smooth, round, narrow, red 
ring, barely or not at all elevated above the surrounding surface. As 
the ulcer grows, the red edge becomes broader and elevated, and the 
surrounding tissue is indurated ; minute raw or pale granulations, 
partly covered with ashy debris, spring from the bottom of the ulcer 
and yield a little ichorous, watery, or thin purulent discharge. The 
induration and elevation increase, and a well-marked indurated or 
" Hunterian " chancre is thus formed. Cracks and abrasions, if left to 
themselves, tend to the same condition. In some cases the pimple never 
becomes pustular, but undergoing enlargement and induration, passes 
into a characteristic red tubercle. 

After a variable interval, secondary symptoms occur, indicating that 
the virus has been absorbed. The earliest and most constant of these is 
bubo. One or more glands in the groin become enlarged, tender, and 
very hard. At first they are not inflamed, their surface is smooth, and 
they readily move under the finger. They may remain in this condi- 
tion for months ; but usually inflammation, acute or chronic, super- 
venes. The gland enlarges, and, the surrounding areolar tissue being 
implicated, it loses its distinctness and mobility. If the inflammation 
be acute, the integument becomes tense and red, and sooner or later 
fluctuation may be felt. 

Among the earliest and most common of the secondary symptoms, is 
ulceration of the membrane of the soft palate and mouth. The ulcers 
are usually superficial, and appear as mere abrasions surrounded by 
slightly elevated rounded smooth margins, about which the epithelium 
has an opaque appearance. They occur on the inner suriaces of the 
lips, at the angles of the mouth, on the sides of the tongue, but chiefly 
on the arches of the soft palate and surfaces of the tonsils. In this last 
situation they are apt to become excavated and ragged. Frequently the 
mucous membrane and submucous tissue of the larynx is similarly 
affected, and the voice becomes gruff and husky. 

This condition of the mucous membrane is almost always associated 
with one or more of the following forms of cutaneous disease. 

Syphilitic roseola. — After slight constitutional disorder, with head- 
ache, and frequently tenderness of the scalp, the trunk, limbs, and face 
become mottled with light mulberry-coloured blotches, not elevated, and 
disappearing on pressure. The epidermis is unaffected, and the spots 
are distinct, and shade off into an indistinctly circular circumference. 
This rash is s!ow in disappearing. It is, I believe, the first stage of the 
leprous affection. Its appearance is usually followed by rapid shedding 
of the hair, leaving the scalp almost bald. 

S. impetigo. — The favourite seat of this eruption is the scalp. It is 
preceded by paiu and tenderness, and commences as distinct red circular 
spots, which become slightly raisei ; a muco-purulent exsudation next 



580 SYPHILIS. 

takes place beneath the epidermis, and the spots are subsequently covered 
with greenish scales. If these be removed, a little depressed, irritable 
sore is exposed, on which the scab reforms again and again. Ultimately 
they heal and leave minute scars. The eruption often appears on the 
face and other parts of the body. — S. ecthyma and rupia are but in- 
creased developments of this form in debilitated constitutions. 

S. lepra appears first as roseola. The injected derma subsequently 
becomes thickened and elevated into a round copper-coloured " 8. tuber- 
cle" or, if less elevated, a slight tumid base, on which the epidermal 
cells become dry and silvery, constituting S. lepra and psoriasis. 

S. lichen. — Small, hard, conical, copper-coloured elevations, formed of 
the hypertrophied papilla3 of the skin, appearing over all parts of the 
body, and being often intensely irritable. Usually they remain dry 
and covered with scaly epidermis, but in persons of enfeebled constitu- 
tion they suppurate, and may then be described as 

S. varioloid eruption. — The lichenous rash may have existed for weeks, 
or have preceded the pustular eruption but a short time. The papules 
exhibit first a little milky serum ; but in about a week they are con- 
verted into pointed, thick-set but discrete pustules, resting on an in- 
flamed, slightly raised, bright rose or copper-coloured base. They 
appear earliest, and in greatest numbers, on the face ; later and more 
thinly scattered on the trunk. A fortnight or three we^ks may elapse 
before the whole of the pustules on the body maturate. The subsequent 
history of the pustule is much the same as that of variola ; but the 
processes of squamation, desquamation, and absorption of the inflamma- 
tory products around the bases occupy a much longer time. Minute 
cicatrices, stained for a long time with a dusky brown colour, remain. 
When the eruption is extensive and well-marked, the patient presents 
the appearance of one covered with small-pox ; but on closer examina- 
tion, the small size of the pustules offer a ready distinction. 

Such is the relationship which careful observation leads me to esta- 
blish between the principal syphilitic skin diseases. 

But the skin and mucous membranes are not the only structures 
affected by the syphilitic virus. The serous and fibrous tissues may be 
involved. The iris, retina, dura mater, and periosteum are all, at a 
later period, liable to be affected. The resulting iritis, retinitis, epileptic 
convulsions, and periostitis, are usually classed as tertiary symptoms. 
The periostitis, if chronic, results in severe neuralgic pains, and nodes : 
if acute, it ends in necrosis. The same poison induces similar morbid 
processes in the viscera. (See Diseases of the Liver.) 

If personal cleanliness be neglected, and the discharges from the 
primary sores be allowed to excoriate the contiguous parts, condyloma- 
tous growths result. It is not uncommon in young females, ignorant 
at first of the nature of the disease, and when informed, ashamed to 
apply for advice, to find the vulva, perineum, and margin of the anus 
covered with condylomatous growths, and the labia and clitoris them- 
selves converted into large mis-shapen pendulous masses, exsuding an 
offensive ichorous fluid. Warts, and probably elephantiasis, have the 
same origin. 



SYPHILIS. 581 

Pathology. — The syphilitic poison, when introduced into the blood, 
causes a low sluggish form of adhesive inflammation, accompanied by 
the effusion of solid unorganized matter. Unlike the solid products of 
common inflammation, this material seems little susceptible of absorp- 
tion or of conversion into fibrous tissue. Like tubercular matter, its 
tendency is to break down and produce unhealthy ulceration. 

Coxtagiox. — A person may become infected with syphilis in three 
ways : — 1. By absorption. 2. By inoculation of the discharge from a 
chancre. 3. By inoculation of the blood of a person in whom secondary 
symptoms are present. The disease is commonly propagated by the 
first mode, the poison being absorbed during sexual intercourse through 
the delicate cuticle into the capillaries of the mucous membrane ; and 
more readily if the cuticle be abraded. 

With regard to inoculation, Ji.Ricord has shown that if a little secre- 
tion from a chancre be taken on the point of a lancet and introduced 
into any part of the skin of a person free from constitutional syphilis, a 
similar infecting chancre is produced there. The following is a descrip- 
tion of its development. During the first twenty-four hours a little 
re iness round the puncture ; from the second to the third day a papular 
elevation seated en an inflamed areola or base; during the fourth day a 
vesicle due to the effusion of turbid fluid beneath the cuticle covering 
the papule ; throughout the fifth day the effusion increases and becomes 
more or less purulent ; the centre of the pustule is depressed, and the 
areola redder and swollen ; during the sixth day the tissue surrounding 
the base of the pustule hardens and feels elastic like fibro-cartilage. 
Subsequently the swelling, induration, and effusion increase, the cuticle 
gives way, a scab forms, and when this is detached the indurated 
chancre above described presents itself. If, however, the syphilitic 
virus have been previously absorbed into, and he actually present in the 
blood of an individual, inoculation of matter from an infecting sore on 
his own person, or on that of another, produces no effect. This non- 
production of a chancre around the point of inoculation is accepted as 
proof that the syphilitic poison already pervades the constitution. It 
would appear that the constitution is infected on or about the fifth or 
sixth day of the development of a primary chancre, that is, at the time, 
when the specific induration appears. If, then, the individual be inocu- 
lated before the fifth day with syphilitic matter from his own developing 
chancre, or from any other source, an infecting chancre will be pro- 
duced around the point. 

As to the third moie of propagation, it has been satisfactorily shown 
that inoculation with the blood of a person affected with secondary 
syphilis will produce an infecting chancre. The disease has been trans- 
mitted in this manner by vaccination, the blood of a child suffering 
from secondary syphilis having mingled with the vaccine matter 
derived from it, imperfectly developed vaccine vesicles have resulted, 
and passed into the condition of indurated chancres — a result the 
more remarkable since the infecting child itself never had the primary 
disease. 



ObZ SYPHILIS. 

Hereditary transmission of Syphilis. — Just as the foetus in utero 
participates in small-pox affecting the mother, so may it be with 
syphilis. Hundreds of sickly infants attest this painful fact. Several 
good observers consider it to be a well-established fact that the infection 
of the infant may take place independently of the existence of a chancre 
or syphilitic bubo in the mother during gestation. 

Origix. — Some authors are of opinion that syphilis had its origin 
in some very remote age, and that it has been transmitted by succes- 
sive contact with infected persons to the present generation. When 
it has been proved that certain conditions, or combinations of circum- 
stances, happened in remote ages, which are never repeated now, we 
may aceept this hypothesis. At present it is more philosophical, and 
more in accordance with what we know of the origin of other con- 
tagious diseases, to assume that the virus is every day generated anew. 

Diagnosis. — The primary sore may be known by the ashy excavation 
or pale warty granulations of the surface, and by the elevated, rounded, 
circumscribed induration which borders and surrounds it. 

TREATMENT. — 1. Local. Before the end of the fifth day the 
primary sore admits of arrest and cure by the application of nitrate 
of silver, strong nitric acid, or caustic potash. When the slough has 
separated, the ulcer may be dressed with black wash or calomel oint- 
ment. If the disease come under notice after induration, local treat- 
ment will be of no service. The sore must be kept clean and free from 
irritation, and constitutional treatment must be adopted. 

II. Constitutional. — This consists in the exhibition of mercury in 
the form of calomel or pilula hydrargyri in small and repeated doses, 
combined, if bubo be present, with the infriction of mercurial ointment 
into the groins until the gums become red, slightly swollen, and tender. 
No disease has a remedy more efficacious than syphilis has in mercury, 
and if the patient be carefully watched even stomatitis need not result 
from its use. Under its influence, the hard effused products melt 
away, the bubo disappears, the ulcer assumes a healthy aspect and heals. 
WTien the constitutional effects of mercury have been thus induced, 
they should be kept up for a time by the occasional use of a little mer- 
curial ointment. 

W 7 hen it is desirable to affect the system speedily, gr. xv to gr. xxx 
of calomel should be sublimed and retained in contact with the person 
by means of a blanket. 

If the primary disease have been treated by mercury, secondary and 
tertiary symptoms, such as the cutaneous and periosteal affections and 
ulceration of the larynx, very readily yield to iodide of potassium, given 
in doses of from gr. iii to gr. x thrice a day. If mercury have not 
been used in the treatment of the primary disease, it must be given in 
combination with iodine. Gr. i to gr. iii hydrargyri iodidi viridis, or 
gr. i to gr. ^ hydrargyri iodidi rubri may be given in the form of 
pills thrice a day ; or the latter may be combined with an excess of 
iodide of potassium, in solution of which it is soluble, and thus given 
in the form of mixture. 



SPERMATORRHEA. 583 

Two other forms of syphilis remain to be described, viz. Infantile 
Syphilis and Local Syphilis. 

Infantile Syphilis. — The child may be born apparently healthy. 
The first symptom which usually appears is inflammation of the nasal 
passages, resulting in a muco-puru.lent discharge, causing obstructed 
nasal breathing. This is popularly known as the snuffles, and the 
child is supposed to have a cold. It now becomes pallid and fretful, 
and rapidly emaciates. After about a fortnight an eruption of copper- 
coloured blotches appears around the anus, the adjacent parts of the 
buttocks, and on the lower extremities. After a time it appears on 
other parts, particularly about the folds of the neck and joints. The 
eruption consists of circular spots slightly raised and subsequently 
covered with thin dryish cuticle (S. lepra), and on the folds of the 
groin, and about the perineum it is apt to become moist and excoriated, 
in which condition condylomata are liable to form. As the disease 
progresses, the intervening skin usually becomes copper-coloured, super- 
ficial ulcers appear on the inside of the mouth, the infant presents an 
extremely cachectic and emaciated appearance, and, if the specific 
remedy be not applied, soon dies of asthenia. 

Treatment. — Gr. i to gr. ii hydrargyri cum creta twice or thrice a 
day, continued until the snuffles and rash have disappeared, and for two 
or three weeks afterwards. 

Local Syphilis. — Mr. Henry Lee recognises four forms of primary 
syphilis : viz. 1st, The indurated chancre. 2nd, The suppurating sore. 
3rd, Ulcerative syphilitic inflammation. 4th, Destructive syphilitic 
inflammation. 

The first form is that which has been already described as producing 
constitutional syphilis. The other three forms of the disease are, 
according to Mr. Lee, purely local, and, as such, never give rise to 
secondary symptoms, or require specific constitutional treatment. The 
secretion of each of these three forms may be artificially inoculated. 



SPERMATORRHEA. 

Symptoms. — Involuntary seminal discharges, occurring either during 
sleep, or in the day-time, and, in extreme cases, on the slightest friction 
or irritation of the genital organs. The constitutional symptoms are 
out of proportion to the loss of fluid sustained, and are due in part to 
the intimate relation subsisting between the sexual function and nervous 
system. They are those of Mimosis Inquieta (p. 264), and Hypochon- 
driasis (p. 418). The patient is restless, listless, timid, and desponding. 
He is subject to flushings of the face, headache, giddiness, noises in the 
ears, disordered vision, dilated pupil, and other symptoms of cerebral 
congestion, to palpitation and shortness of breath. He is easily startled 
by noises and readily irritated, and has various nervous feelings, as of 
cold water trickling down the back, or of ants crawling over the skin : or 



584 SPERMATORRHOEA. 

weakness and numbness of the hands. His memory fails, and his intellect 
grows weak ; he hesitates, and often stammers in his speech. Jn the most 
severe cases, the patient's mind is still more seriously affected. His spirits 
are depressed ; he is addicted to silence and solitude ; is timid and morose ; 
believes himself to be the object of plots and persecutions ; grows weary 
of life, and is tempted to commit suicide ; and, at length, becomes the 
confirmed victim of monomania or dementia. Among the occasional 
symptoms and consequences of this affection are impotence, rigid con- 
traction of the limbs, paralysis agitans, epilepsy, strabismus, amaurosis, 
bulimia, and nervous asthma. 

Causes. — Sexual excesses; masturbation, pruritus scroti, ascarides, 
haemorrhoids, fissures of the anus, and stricture of the rectum ; blisters, 
and cantharides taken internally ; sleeping on the face. 

Diagnosis. — The fluid is identified as coming from the vesiculae 
seminales by the physical and microscopic characters of the semen (see 
Fig. 28, p. 135). In one case which came under my notice, the patient 
mistook an abundant pale sediment of urate of ammonia (Fig. 17, p. 129;, 
completely dissolved by heat, for semen. G.) The urine alleged to con- 
tain semen should always be submitted to examination. 

Prognosis. — Favourable in those cases in which the discharge is 
nocturnal, and always preceded and accompanied by the usual sexual 
phenomena. Less favourable in those cases in which the discharge is 
diurnal, and produced by slight causes affecting the state of the genital 
organs. Most favourable when traceable to mechanical causes in the 
rectum, urethra, or scrotum. 

Treatment. — The patient often requires comfort more than medi- 
cine. As a general rule, cases in which the emissions are nocturnal, and 
accompanied by the usual sexual phenomena, admit of cure by abstinence 
from any bad habits which may have caused them. 

The treatment by medicine will consist in all cases of aperients re- 
gularly administered, to secure an open state of the bowels (aloetic 
aperients and hypercatharsis are contra-indicated), and such further 
remedies as are adapted to the existing state of the system. If nervous 
symptoms predominate, the treatment prescribed under Mimosis In- 
quieta; if the patient be pale and anaemic, the treatment proper to 
Anaemia. If ascarides be present, the remedies for the removal of the 
same. Piles require the treatment recommended at p. 519. If cutaneous 
eruptions near the parts of generation be the cause of irritation, these 
will require the treatment proper to the particular skin disease. Prostatic 
disease, stricture of the rectum or urethra, and fissures and painful 
tumours on the anus, require the interference of the surgeon. The 
careful avoidance by patients suffering from this disease of advertising 
quacks cannot be too strongly insisted upon. 



( 585 ; 



CHAPTEE VIL 

DISEASES OF THE ORGANS OF SENSE. 

1. Diseases of the Eye. 

2. Diseases of the- Ear. 

DISEASES OF THE EYE. 

1. Conjunctivitis. 

2. Sclerotitis. 

3. Corneitis. 

4. Iritis. 

5. Diseases of the Choroid. 

6. Diseases of the Retina. 

7. Diseases of the Choroid and Retina. 

8. Diseases of the Lens, 

9. Staphyloma Posticum. 

10. Glaucoma. 

11. Other Diseases and Defects of the Eye. 

INFLAMMOTION OF THE CONJUNCTIVA. 

Species. — 1. Catarrhal Ophthalmia. 2. Purulent Ophthalmia of 
Infants. 3. Purulent Ophthalmia of Adults. 4. Gonorrheal Oph- 
thalmia. 5. Strumous Ophthalmia. 

1. CATARRHAL OPHTHALMIA. 

Symptoms. — Redness and itching of the conjunctiva, lachrymation, 
slight intolerance of light, and stiffness of the globe of the eye, followed 
by pricking pain, the sensation of a grain of sand beneath the eyelid, 
and adhesion of the eyelashes, ou first waking in the morning. The 
inflammation begins in the conjunctiva of the lids, and gradually extends 
towards the cornea. In acute forms of the disease, the whole eye is 
covered with a vascular network, the secretion becomes puriform or 
muco-purulent, and patches of extravasated blood are effused beneath 
the conjunctiva. If the disease extend to the conjunctiva covering the 
cornea, vision is obscured. There is no constitutional disturbance, beyond 
the slight feverishness attendant upon the catarrh. 

Causes. — Catarrh ; a draught of cold air directed on the eye ; foreign 
bodies in the eye; over-exertion of the sight; the glare of a strong 
light ; all the causes of inflammation in other mucous membranes. 



586 PURULENT OPHTHALMIA OF CHILDREN. 

Diagnosis. — From purulent ophthalmia, except in severe cases, by 
its milder character, and by not being contagious. From inflammation 
of the sclerotic, by the brighter colour, larger size, and more tortuous 
course of the vessels, which are obviously superficial, and shift their 
place with the motions of the eyelids ; by the abundant secretion ; by 
the absence of acute pain in and around the orbit; and by the slight 
intolerance of light, existing chiefly at the onset of the attack. 

Prognosis. — Favourable. The disease readily yields to treatment, 
and, when confined to the conjunctiva, does not threaten the loss of 
vision. In chronic cases, or after repeated attacks, the lids may become 
thickened, and that part of the membrane which covers the cornea may 
be rendered opaque, so as to impair the sight. 

Treatment. — That proper to catarrh. Dover's powder may be 
given at night, with a saline aperient in the morning ; or small doses of 
tartar-emetic, in combination with a saline aperient, two or three times 
a day. 

The local treatment will consist, in severe cases, in the application of 
a blister, or a few leeches to the temple, with fomentations of warm 
water or warm decoction of poppies. When the inflammation has in 
some degree subsided, and in mild cases from the first, collyria (Form. 
39) will be needed. A large drop or two (Form. 39) being placed be- 
tween the lids at the outer angle twice or thrice a day. Adhesion of the 
eyelids must be prevented by introducing spermaceti or zinc ointment 
between them at bedtime. 



2. PURULENT OPHTHALMIA OF CHILDREN. 

Symptoms. — Inflammation in the conjunctiva covering the lids, 
commencing generally on the third day after birth, and extending over 
the entire surface of the eye, accompanied by intolerance of light, swelling 
and firm adhesion of the lids, and a copious discharge of purulent matter, 
which issues in large quantities on their separation. The membrane is 
of a bright scarlet colour. The discharge is generally yellow, but some- 
times greenish, or tinged with blood ; or ichorous. The disease may 
continue for eight or ten days, without involving the transparent parts 
of the eye ; but if it be not properly treated, ulceration occurs at the 
circumference of the cornea, which first becomes hazy, then opaque, and 
finally sloughy and infiltrated with pus. Sooner or later it gives way, 
and the iris protrudes. If the inflammation of the cornea stop short of 
ulceration it becomes opaque and usually adherent to the iris. 

The constitutional symptoms are restlessness, sleeplessness, and dis- 
ordered bowels, — results of the prolonged local irritation. 

Diagnosis. — There is no other disease of the eyes occurring at this 
early period with which it can be confounded. 



PUEULENT OPHTHALMIA OF ADULTS. 587 

Prognosis, — Favourable, so long as the cornea retains its trans- 
parency. 

Causes. — The application of leucorrhceal or gonorrheal discharges 
to the eye, during parturition ; contagion. 

Treatment. — Few diseases require more assiduous attention, and 
few so rapidly yield to treatment ; neglect for a single day may result 
in permanent loss of vision. Six times a day the lids must be carefully 
separated, and the surface of the conj unctivas freely washed with warm 
water by means of a syringe, and one or two drops of solution of nitrate 
of silver (gr. ii to gr. iv to ^j), or of alum (gr. viii to gr. x to ^j) 
dropped into the eye just within the outer canthus. The lids should 
then be smeared with a little olive oil ; and lint wetted with water 
should be kept constantly applied to them. In chronic cases, when the 
lids present a granular appearance, they may be touched with the solid 
nitrate of silver or sulphate of copper. 

The bowels should be kept free by gentle aperients of castor-oil, mag- 
nesia, or manna. 

Prophylaxis. — The greatest care should be taken to prevent the 
application of the matter to the eyes of other persons. 



3. PUEULENT OPHTHALMIA OF ADULTS. 
Synonym. — ^Egyptian ophthalmia. 

Symptoms. — The disease generally attacks both eyes, and sets in 
with a sensation of a foreign body beneath the eyelids, speedily followed 
by injection of the conjunctiva, effusion of serum beneath it, and a thick 
puriform discharge from the surface. The conjunctiva is of a bright- 
red colour, the lids and anterior surface of the eye are swollen and 
granular, and the cornea is sunk, as it were, into a deep pit formed by 
the projection of the conjunctiva. There is, here and there, extravasated 
blood. So long as the conjunctiva alone suffers, the pain is inconsider- 

: able ; but when the deeper-seated textures are involved, the pain is 
extremely severe. In the globe itself, it is a sensation of painful tension, 

; and around the orbit, a pain like that of hemicrania. It is intermittent, or 
aggravated at intervals, and attains its greatest intensity at night. 

1 There is but little intolerance of light in any form of the disease. 
Eupture of the cornea sometimes takes place with permanent or tem- 

I porary relief to the pain. The constitutional symptoms are slight ; the 
sleep is disturbed by paroxysms of pain. 

Terminations. — In resolution ; chronic inflammation ; granular 
conjunctiva ; opacity ; ulceration or sloughing of the cornea ; staphy- 
loma ; prolapsis of the iris. The disease is very apt to recur. 

Causes. — Contagion. The common causes of inflammation. 



o88 GOXOERHGEAL OPHTHALMIA — STRUMOUS OPHTHALMIA. 

Diagnosis. — From catarrhal ophthalmia by its greater severity, and 
the greater tendency to attack the deeper-seated parts. From diseases 
affecting the deeper-seated tissues alone, by the presence of severe in- 
flammation of the conjunctiva. 

Prognosis. — Unfavourable, when very severe, or neglected at its 
outset. From its tendency to attack the deeper-seated structures of the 
eye, loss of vision, or at least injury to the sight, may be anticipated. 

Treatment. — Leeches round the orbit ; free scarification, followed 
by strong astringents (Form. 182). In chronic cases, the vinum opii 
may be used with advantage. Previous to the application the surface 
of the eye should be carefully cleansed by a syringe. Aperients should 
be administered at the outset ; the patient should be put on a spare diet, 
and enjoined to take gentle exercise in the open air. When the deeper- 
seated textures of the eye are implicated, the remedies appropriate to 
the inflammations of those textures should be employed ; such as the 
belladonna ointment in threatened adhesion of the iris ; puncturing the 
cornea to prevent rupture of the membrane ; the application of nitrate 
of silver to ulcers on the cornea, or to the protruding iris. 

Prophylaxis. — Great care should be taken to prevent the applica- 
tion of the matter to the eyes of healthy persons. 



4. GONORRHEAL OPHTHALMIA. 

Symptoms and Treatment. — Those of purulent ophthalmia of 
adults ; but it is more severe and much more rapid : a few hours may 
suffice for its complete development. In order to arrest it, we may pass 
solid nitrate of silver rapidly over the inflamed conjunctiva. 

Cause. — Inoculation of the eye with gonorrhoea! matter. 



5. STRUMOUS OPHTHALMIA. 
Synonyms. — Scrofulous, pustular, and phlyctenular ophthalmia. 

Symptoms. — This disease attacks children from the period of wean- 
ing, to eight or nine years of age, and sometimes up to puberty. There 
is slight and partial redness of one, or of both eyes, sometimes confined 
to the eyelids, and caused by groups of enlarged vessels running from 
the circumference of the eye to the edge of the cornea, where they ter- 
minate in small pustules, which break and form minute ulcers. Some- 
times the injection extends to the conjunctiva covering the cornea, and 
pustules form on its surface. There is great intolerance of light, the 
eyebrows are contracted, and the nostrils and upper lip drawn upwards. 
Whenever the eye is exposed to light, there is a profuse discharge of 
scalding tears, w r hich, flowing over the skin, irritate and inflame it. 



SCLEROTITIS. 589 

The symptoms remit towards evening. The constitutional symptoms 
are those of scrofula, such as glandular enlargements, eruptions on the 
head and face, sore ears, general debility, tumid belly, disordered bowels, 
offensive breath. 

Causes. — Predisposing. The scrofulous diathesis, and all the cir- 
cumstances calculated to call it into action. — Exciting. The common 
causes of inflammation : catarrhal ophthalmia ; the exanthemata. 

Diagnosis. — From catarrhal ophthalmia, by the more partial injec- 
tion of the vessels, the greater intolerance of light, the formation of dis- 
tinct pustules, and the presence of other symptoms of scrofula. From 
purulent ophthalmia, by the watery discharge — lachrymation. 

Prognosis. — Favourable, when the scrofulous taint is slight. — Un- 
favourable^ when it is strongly marked. 

Terminations. — In resolution ; in the 'formation of a " vascular 
speck," or of p annus ; in ulceration of the cornea, followed in some 
cases by protrusion of the iris, and its adhesion to the cornea ; in infil- 
tration of the cornea. 

Treatment. — I. General. That recommended for scrofula (p. 345), 
Quinine is a most valuable tonic in this disease. II. Local. Warm fo- 
mentations to the eye ; the instillation of vinum opii two or three times 
a day, or the use of astringent collyria, with the red precipitate or citrine 
ointment, placed between the lids at bed-time ; and by the counter- 
irritation of blisters behind the ears, an issue in the arm, or a ring or 
thread passed through the lobe of the ear. Ulcers on the cornea should 
be touched with nitrate of silver. 



SCLEROTITIS— INFLAMMATION OF THE SCLEROTIC. 

Synonym. — Rheumatic ophthalmia. 

This disease is sometimes limited to the sclerotic, but more frequently 
coexists with inflammation of the conjunctiva (catarrho-rheumatic oph- 
thalmia^), or of the iris. 

Symptoms. — A deep-seated and dusky redness of the globe of the eye, 
especially round the cornea, where the radiating straight vessels of the 
sclerotic are seen abruptly terminating a short distance from its margin. 
There is an abundant flow of tears, extreme intolerance of light, and a 
sensation of fulness and tension, with daiting pain in the globe, extend- 
ing round the orbit, in the course of the branches of the fifth nerve, 
increasing towards evening, attaining its greatest intensity at midnight, 
and subsiding towards morning. There is generally some degree of 
haziness of the cornea, and vision is more or less impaired. 

Termination. — In recovery, or in chronic disease. If the disease 
extend to the cornea or iris, the results of inflammation of those parts. 



590 CORNEITIS. 

Causes. — Predisposing . Middle age ; the male sex ; a previous 
attack; the rheumatic or gouty diathesis. — Exciting. The common 
causes of inflammation. The disease is simply local rheumatism. 

Diagnosis. — From inflammation of the conjunctiva by the deep- 
seated redness, radiated arrangement, and hair-like firmness of the vessels ; 
by the secretion of tears in the place of mucus ; by the deep-seated pain 
of the orbit, extending to the surrounding parts ; by the intolerance of 
light ; in some cases, by its complication with iritis. 

Prognosis. — Favourable, if the disease be promptly treated. It 
verv liable to assume a chronic form, and to return. 






Treatment. — An alterative purgative followed by a full dose of the 
sodas et potassae tartras combined with rr\xv vini colchici. Quinine with 
the vegetable acids. Gr. x pulvis ipecacuanhas compositi. 

A solution of extract of opium to be occasionally dropped into the eye, 
which should be protected by a shade, or the patient should remain in a 
darkened room. Warm opium fomentation. Unguentum belladonnas 
should be rubbed into the forehead, and smeared over the eyelid and 
brow. Chloroform and opium liniment may be used with the same view. 
If the inflammation be very acute, leeches to the temple or behind 
the ears. In obstinate cases of chronic disease, arsenic (Form. 326). 

The symptoms, terminations, and treatment of the disease are those of 
catarrhal inflammation of the conjunctiva, combined with those proper 
to rheumatic inflammation of the sclerotic. 



CORNEITIS— INFLAMMATION OF THE CORNEA. 

Symptoms. — The disease begins with a slight haze on the cornea, 
which gradually increases till it amounts to opacity. Numerous minute 
ulcers now fonn on the surface, and the vessels of the conjunctiva and 
sclerotic become injected; those of the conjunctiva ramifying over the 
surface of the cornea, and those of the sclerotic being arranged in the 
characteristic radiated form round the margin of the cornea. Deposi- 
tions of lymph between the layers of the cornea are also of frequent 
occurrence ; and the secretion of the aqueous humour being augmented, 
increases the convexity of the membrane. During the progress of the 
disease pus may form within the layers of the cornea, appearing as a 
yellowish-white spot. In such a case the posterior lamina may give way, 
when the pus is discharged into the anterior chamber and sinks down to 
the lower part, forming a yellow crescent (hypopyon) ; or the fibres of 
the anterior elastic lamina may be destroyed and a minute ulcer result. 
Such ulcers readily heal ; but the cicatrix always remains opaque. There 
is generally considerable lachrymation and intolerance of light. The 
pain is usually slight, except occasionally in the first stage, when there 
is a sense of tension in the eye. with darting pains in the forehead. 



IDIOPATHIC IEITIS. 591 

Diagnosis. — From other chronic affections of the eye, by a plexus of 
very fine vessels arranged in the form of a crescent at the edge of the 
cornea. Sometimes these vessels form an almost complete circle. 

Prognosis. — Unfavourable, when the general health is impaired. 

Treatment. — That recommended under Sclerotitis. Quinine is 
particularly useful in this, as in strumous ophthalmia. Should inflam- 
mation of the surrounding textures, and of the iris, take place, the 
treatment proper to iritis will become necessary. 



IRITIS— INFLAMMATION OF THE IRIS. 

Species. — Idiopathic. Specific. 

idiopathic iritis. 

Symptoms. — The disease begins by the formation of a red zone of 
small, straight, parallel vessels, arranged as radii round the circum- 
ference of the cornea, and terminating abruptly near its edge, the red- 
ness after a time extending to the conjunctiva. The iris loses its bril- 
liancy, becomes muddy, and of a tint formed by blending a red with 
its original hue ; its texture is at the same time impaired or destroyed, 
and lymph is largely effused into its substance from its edge, or its 
anterior or posterior surface, or in all these situations. Sometimes 
the quantity effused is so large as to fill the chambers of the eye. The 
movements of the iris are at first impeded, and then suspended ; the 
pupil contracts, and becomes irregular in shape, from effusion into its 
substance and adhesion to surrounding parts. There is dimness, and 
at length complete loss, of vision ; and generally severe pain in and 
round the orbit, darting to the cheek and temple, and worse at night. 

Diagnosis. — By the change of colour of the iris, the irregular pupil, 
and the effusion of lymph behind the cornea. 

Prognosis. — Unfavourable, when the treatment has been delayed. 
A contracted pupil, great vascularity, acute and deep-seated pain, dim- 
ness of vision, or insensibility to light. — Favourable, in mild cases, and 
in acute cases, promptly treated. 

Causes. — Mechanical injuries, surgical operations, over-exertion of 
the eyes, and the common causes of inflammation. 

Treatment. — Indications. I. To subdue inflammation. IJ. To 
prevent the effusion, and promote the absorption of lymph. III. To 
dilate the pupil and prevent the formation of adhesions. 

I. Leeches to the temple, brisk aperients, a strict antiphlogistic 
regimen, the exclusion of light, and perfect rest. 

II. To fulfil this indication, calomel and opium must be given from 
the outset, in doses of gr. J to gr. i, with from a quarter to half a 
grain of opium, every three, four, or six hours, according to the severity 



592 SPECIFIC IRITIS. 

of the symptoms; combined, in very severe cases, with mercurial 
inunction. The calomel and opium may be advantageously combined 
with tartar-emetic in the dose of from a sixth to a quaiter of a grain. 

111. This indication is fulfilled by occasionally dropping a little 
liquor atropine into the eye. 

SPECIFIC IRITIS. 

Varieties. — Syphilitic ; Rheumatic ; Arthritic ; Strumous. 

Syphilitic Iritis. — The symptoms resemble those of idiopathic 
iritis, but generally come on slowly and insidiously. When fully estab- 
lished, the disease may prove highly destructive. The cause, as the 
name implies, is the syphilitic virus. The disease may occur alone ; 
or in combination with other secondary symptoms ; and it may make 
its appearance during the existence of the primary disorder. The 
diagnosis turns on the position in which the lymph is effused, and on 
its appearance. It is thrown out on the margin of the iris in the form 
of globules or distinct masses, of a reddish, brownish, or brownish- 
yellow colour, sometimes described as tubercles. At the same time the 
pupil is displaced upwaids and inwards, the sclerotic zone is of a cinna- 
mon colour, and small brown spots form on the cornea. The treatment 
consists in inducing the constitutional effects of mercury, as speedily as 
possible, by the exhibition of calomel and opium, and the infliction of 
mercurial ointment into the armpits or groins. Atropia must be used 
to dilate the pupil. 

Rheumatic Iritis. — The symptoms axe usually associated with these 
of sclerotitis (see p. 589). The sclerotic, however, has a peculiar 
purplish hue, and the radiating vessels stop within one or two lines 
of the margin of the cornea, leaving a bluish-white ring around it, — 
appearances which are characteristic of this affection. Blood-vessels 
become visible in the iris. Deposition of fibrin is rare ; and when it 
does occur is small in quantity, and effused round the pupillary margin. 

Cause. — Exposure of the eye to a draught of cold air. 

Treatment. — That of sclerotitis (see page 589), care being taken 
to prevent adhesion of the iris to the capsule of the lens by the use of 
liquor atropiae. Mercury is of little or no use in this form of disease. 

Arthritic Iritis. — The disease occurs in persons subject to gout, 
or of gouty constitution, when weakened by abstinence, or other occa- 
sional cause of debility. The symptoms resemble those of rheumatic 
iritis. The disease is very apt to recur. The general treatment of the 
acute disease is that of rheumatic iritis and gout. 

Strumous Iritis. — This form is generally the result of an extension 
of strumous ophthalmia to the deeper-seated structures, and is chionic 
and obstinate. The constitutional treatment is that of scrofula ; the 
local treatment being determined by the degree and extent of the in- 
flammation. Solution of atropia must be used as in the other forms of 
iritis. 



( 593 ) 



USE OF THE OPHTHALMOSCOPE. 

In order to ascertain the state of the deeper structures of the eye, 
the ophthalmoscope is indispensable, and a few words on its manage- 
ment will not he out of place here. 

If we wish to explore the whole fundus of the eye, the pupil must 
be well dilated by instilling a few drops of solution of atropine. But 
as the pupil does not regain its contractility for some time, we must 
use the solution as seldom as possible, and we may even dispense with 
it when a glance at the optic nerve and the parts immediately surround- 
ing it is all that is wanted. Let the patient be seated in a dark room, 
and place an argand gas-light, or moderator lamp, just behind his 
shoulder and close to the side of his head, so that the light is on a level 
with the eye and so far behind it that the face is in the shade. Stand 
or sit opposite the patient, apply the ophthalmoscope to your own eye, 
at a distance of eighteen inches from the eye of the patient, and, looking 
attentively through the sighthole, direct the rays reflected from its 
mirrored surface so as to fall on the patient's eye. Next interpose the 
lens at the distance of about an inch in front of the patient's eye, and 
then by a slight backward and forward movement of your own head 
and the speculum together, catch the proper focal distance, and the 
image of the fundus of the eye will appear as a reddish glow. On 
careful examination, the following parts maybe distinctly made out: — 

Normal Appearance of the Fundus of the Eye. — Figs. 79 
and 80. — The entrance 

of the optic nerve (optic Fig. 79.* 

disc, optic papilla) is 
seen as a white or rosy- 
tinted circular spot li- 
mited by a sharp, well- 
defined, circular line, 
formed internally of the 
margin of the choroid, 
externally of the margin 
of the sclerotic. The 
margin is slightly raised 
above the general con- 
cavity of the fundus, 
while its central parts 
are slightly depressed 
below it. A little to 
the inside of the optic 
entrance the yellow spot 
may be seen : it is the 
darkest part of the 
fundus, forming a dusky oval or roundish patch, as large as, or smaller 

* Fig. 79 represents the retina spread open ; the parts are of natural size ; the 
yellow spot, and a little below and to the inner side, the optic nerve entrance 
and the retinal vessels are seen. 

2 Q 




594 



DISEASES OF THE CHOROID. 



than, the optic entrance. In the centre may be distinguished a small 
bright dot, the fovea centralis. The optic entrance and yellow spot 
are surrounded by an orange-red field, varying in intensity of colour 
according to the complexion, and pervaded by the retinal vessels. The 
retinal artery and vein, in obtaining entrance into the eye, perforate 
the optic entrance, where each consists of from one to three trunks ; the 
artery is distinguished from the vein by its smaller size, its scarlet 

colour, and its dichoto- 
Fig. 80 * mous ramifications. The 

veins are more tortu- 
ous, and receive branches 
at considerable angles. 
Leaving the optic en- 
trance, these vessels are 
seen to ramify freely 
over the surface of the 
retina, diverging above 
and below the yellow 
spot so as to avoid it, 
and spreading their fine 
terminal branches to- 
wards the anterior edge 
of the retina. 

The different parts of 
the fundus are succes- 
sively brought into view 
as the patient moves his 
eye outwards or inwards, 
downwards or upwards. 
The yellow spot, being in the axis of the eye, will be seen when it 
is directed straight forward ; the optic entrance, which is ^ of an inch 
internal to and a little below the yellow spot, will be visible when the 
eve is rolled a little inwards. During the examination of a particular 
part of the fundus, the patient should be directed to fix his eye on a 
number, marked in large characters on a screen. 

In dark-complexioned persons the choroid vessels cannot be distin- 
guished ; but in those who have light hair and blue eyes, they may be 
readily seen, and even the arrangement of the vasa vorticosa observed. 
In Albinos it is possible to see, through the choroid, the ciliary arte- 
ries in the sclerotic. 




DISEASES OF THE CHOROID. 

This membrane being essentially composed of a fine network of deli- 
cate blood-vessels, is liable, not only to participate in several constitu- 
tional diseases, but also to implicate in its own disorders those important 

* Fig. 80 represents the healthy fundus as magnified by the ordinary lens : 
the optic nerve entrance, and the distribution of the retinal artery and nerve 
are shown. 



INFLAMMATION OF THE CHOROID. 



595 



parts of the eye which are dependent on it for nutrition or otherwise 
intimately associated with it. Lying between the sclerotic and retina, 
and forming anteriorly the choroid body and the iris, every change of 
the choroid must, in a lesser or greater degree, affect these continuous 
and contiguous parts also. 

Congestion of the Choroid. — Morbid Appearances. Increased 
redness of the fundus, and enlargement, with more or less tortuosity of 
the blood-vessels. ' As the colour of the fundus varies in intensity in 
different people, we can only diagnose the condition satisfactorily by a 
comparative examination of both eyes. 

Symptoms. — Pain, or aching fulness, intolerance of light, lachry- 
mation. 

Inflammation. — Morbid Appearances. Those of congestion in 
a higher degree, with effusion, either between the choroid and sclerotic, 
or between the choroid and retina, or bursting through the latter and 
escaping into the vitreous humour. The choroid itself may be swollen 
and opaque from interstitial effusion. In the disseminated and syphi- 
litic varieties white patches or rounded spots of effusion, and black 
spots, composed of masses of pigment epithelium, are seen on the surface 
of the choroid. Capillary haemorrhage is not common ; when it does 
occur the extravasation is more extensive and less defined than when 
occurring in the retina. The effused serum in front of the choroid 
may be deeply stained 
with blood. If the in- 
flammation continue it 
soon affects the vitreous 
humour. which becomes 
hazy. [£ the effused 
products have been 
limited to the substance 
of the choroid, they 
may be absorbed, and 
the eye recover. If the 
inflammation take on 
the suppurative form, 
it may rapidly spread 
and disorganize the 
whole eye. Recovery 
is generally incomplete, 
for as the exsudation 
is removed, the choroid 
undergoes atrophy, the 
pigment cells are de- 
stroyed at the points 

where the inflammation developed itself, and corresponding parts of 
the surface of the white sclerotic are exposed. The fundus therefore 
presents yellowish-white patches with ragged margins, bounded bv 
and dappled over with, the black unaltered choroidal epithelium. \i' 



Fig. 81. 




596 DISEASES OF THE RETINA. 

the inflammation have been more diffuse, only small black islands of 
unaltered pigment are left scattered over the pale fundus. The retinal 
vessels are seen undisturbed in front of this mottled field. (Fig. 81.) 

Symptoms. — Those of congestion of the choroid, but more intense. 

The external symptoms are usually little marked. In some cases 
the;e is no external indication of disease. When the ciliary processes 
are involved, there is vascularity of the corresponding part of the 
sclerotic, and fulness of the veins. The pupil is usually inactive. 

Terminations. — Staphylomatous protru.-ions of the sclerotic, form- 
ing blue tumours close to the margin of the cornea. Glaucoma is no 
doubt a frequent result of choroiditis. 

Treatment. — In congestion of the choroid the patient should avoid 
bright light, read little, and use large type. The cold douche should 
be frequently applied to the eyes, and occasionally to the whole head. 
If debility be present, quinine with mineral acids or the astringent 
chalybeates. When inflammation occurs, leeches or blisters to the 
temples ; calomel and opium given to slightly affect the gums ; and 
exclusion from light. 



DISEASES OF THE RETINA. 



Anaemia may arise from a general anaemic condition or from the 
obstruction of the retinal artery by an embolus. In the first case there 
is simple pallor of the optic disc, rendering the veins very conspicuous. 
The symptoms are fatigue and dimness of vision. When it aiises from 
blockade of the retinal artery, its branches are seen empty and con- 
tracted and the veins collapsed. Blindness, occurring suddenly, is the 
result. 

Atrophy of the Optic Disc and Retina. — Optic disc atro- 
phied, sunken, pearly white, and very conspicuous; retinal vessels 
contracted. Retina near optic disc and yellow spot opaque and white. 
This condition is indicative of atrophy of the intercranial portion of the 
optic nerve constituting the so-called " cranial amaurosis." 

Symptoms. — Obscurity of vision coming on gradually or suddenly, 
followed by insensibility of the greater portion of the retina. The 
fingers can be dimly seen only in a certain limited position. 

Imbibition and Swelling of the Optic Nerve, with Fatty 
Degeneration of the Retina. — Morbid Aprpearances. Spots of an 
intense white colour streaking the optic disc, indicating commencing 
induration of the nerve fibres ; small white points grouped in the form 
of a star near the yellow spot, resulting from fatty degeneration of the 
anterior extremities of the radial fibres of the retina. Numerous 
minute linear extravasations of blcod lie between the altered fibres, 
and give a more decided appearance of radiation to the diseased patch 
of retina. In a more advanced stage, the swelling of the optic disc 
almost disappears, and the fundus is occupied by a patch of pearly 
whiteness, spotted and striated here and there, by minute extravasations, 



DISEASES OF THE RETINA. 597 

and limited by an irregular dotted margin. The degenerate arteries 
and tortuous veins appear very distinct as they radiate over this 
mottled white field. 

Symptoms. — Dimness of vision gradually increasing to complete 
blindness, without pain or external symptoms. 

Cause. — " This condition of the retina is so characteristic of Bright's 
disease that it allows one, by ophthalmoscopic examination alone, to 
recognise with certainty the affection of the kidney." (Liebreich, 
Atlas der Ophthalmoscopie, p. 25.) 

Retinitis.— JTorbid Appearances. Redness of the optic disc, be- 
coming intense, obscuring its outline, and gradually increasing until it 
is lost to view ; retinal veins enlarged and varicose. Sometimes the 
fundus is dotte.l over with red spots of blood; thickening of the retina 
by serous infiltration, and diminution of its transparency, so that the 
deeper portions of the veins cannot be seen, and they have the appear- 
ance of being interrupted. In proportion to the quantity and density 
of the opaque inflammatory products, the red colour of the choroid be- 
comes dimmed, and at last obscured, so that the retina is alone seen. 
It is of a dull drab or grey colour, and may present here and there 
patches of ecchymosis. 

In the sypldlitic variety the affected portion of the retina is ren- 
dered opaque by solid effusion forming a white patch, stretching from 
the obscuie margin of the optic disc round the yellow spot, and thence 
spreading as a streak towards the circumference. It is distinguished 
from the degeneration occurring in Bright's disease, by the absence of 
the sharp definition and vivid whiteness. 

Symptoms. — Dim and distorted vision, lines appear zigzagged, and 
vertical objects out of the perpendicular ; occasionally fiery flashes are 
noticed ; there is often considerable pain in the head. 

Causes. — Strong light ; the heat and light of large fires ; light re- 
flected from snow or sand ; lightning ; overstraining the eye in examining 
very minute objects. 

Treatment. — That of local inflammation. Quinine should be given 
early. If there be syphilitic taint, the treatment given p. 582. 

Retixal ELe:morrhage (Retinal apoplexy). — Morbid Appearances. 
Extravasation of blood in spots, streaks, or patches. The eriusion may 
take place between the layers of the retina; upon its surface, between 
it and the lining membrane ; or it may rupture the latter, and pass 
into the vitreous humour. When recent, the colour of the effusion is 
crimson, afterwards black or brown. 

Sympjtoms. — More or less imperfect vision coming on suddenly after 
exertion in a stooping posture, or after a blow on the globe of the eye. 
Only the half of an object may be seen. There are usually dilatation, 
sluggish action, or immobility of pupil. Small objects cannot be 
distinguished; but light, and large objects often appear of a deep 
red tint. Except in case of violence, there is no pain or intolerance of 
light. 

Causes. — Violent straining, congestion of the retina ; suppression of 



598 DISEASES OF THE CHOROID AND RETINA. 

the menses ; degeneration of the coats of the retinal vessels ; blows of 
the eyeball ; convulsions ; apoplexy ; Bnght's disease. 

Prognosis. — Dependent upon the cause. Favourable if the patient be 
young, and the effusion small. Unfavourable in proportion to the 
amount of direct violence, to the imperfection of vision, to the inac- 
tivity of the iris, and to the presence of intra-ocular or intercranial 
pain. 

Treatment. — Leeches to the temples, a brisk hydragogue purgative, 
and the constant application of cold to the eye. If pain be present, 
opium may be given. If light be intolerable, the patient must be kept 
in the dark ; and in every ca-e diiect light must be avoided. The 
sound eye must not be used in reading or fine work. 

Under the most favourable circumstances, the effusion is slowly ab- 
sorbed and the function of the retina tardily restored. 



DISEASES OF THE CHOROID AND RETINA. 

Choroido-retinitis pigmentosa. — Morbid Appearances. — Those 
of atrophy. The choroid and retina are atrophied, speckled with pig- 
ment, and unnaturally adherent. The disease is characterised by com- 
mencing in a more or less complete circle at the oia serrata (ant. 
margin of retina), and spreading backwards towards the optic disc, 
which ultimately becomes implicated in the atrophy. 

Symptoms. — A general contraction of the field of vision, while the 
central parts retain their clearness ; in two words — circumferential 
blindness. When the disease has made considerable advance towards 
the centre, night blindness occurs. The progress of the disease is often 
very slow, and there are no external evidences of its presence. As the 
fundus becomes affected, blindness creeps on, and the pupil becomes 
large and inactive. Total blindness at last results. 

Causes. — Chronic inflammation and defective nutrition. 

Detachment of the Retina from the Choroid) Floating 
Retina). — Morbid Appearances. If the displacement be extensive, it 
is readily observed ; if slight it is ascertained with difficulty. It is first 
seen at the lowest part of the fundus, probably in consequence of the 
gravitation of the effused fluid. If this be serum, the detached retina 
projects into the vitreous humour as a tense vesicle, or folded membrane 
which vibrates or undulates with every movement of the eyeball. The 
limit of detachment is marked by the sudden bending of the vessels and 
by a diminution in the colour of that portion of the fundus which is 
detached. In the earlier stages the colour of the choroid is transmitted 
through the retina, which still retains its natural transparency. In 
long-standing cases the detached retina becomes pearly white and 
opaque, and the colour of the choroid is no longer apparent. The 
separation of the retina may be partial, or it may increase until it is 
wholly disunited from the choroid. It is then pushed forwards in the 
form of an irregular hollow cone, the apex of which is formed by the 



DISEASES OF THE SCLEKOTIC AND CHOROID. 



599 



optic disc. In extreme cases it is reduced to a mere translucent cord 
traversing the posterior part of the axis of the globe. 

Symptoms. — The disease comes on so insidiously, that the blindness 
caused by the disease is often discovered accidentally. There is no pain, 
and the appearance of the eye is quite natural. If the condition be 
manifest, then obliteration of the field of vision, corresponding to the 
limited detachment of the retina, is observed. If the lower half of the 
nervous layer be detached, then the field of vision is terminated by an 
irregular horizontal line, above which is darkness. 

Diagnosis. — Cancerous tumours of the choroid may coexist, and be 
overlooked, in this condition of the retina. Effusions into and opaci- 
ties of the vitreous membrane may be mistaken for it ; the absence of 
these latter conditions is determined by the appearance of the retinal 
vessels in the projection. 

Cause. — Inflammation of the retina or choroid. 

Treatment. — If the retina be wholly detached, the sight will never 
be regained. In cases of partial separation, the absorption will be 
promoted by the repeated application of blisters to the temple, and a 
prolonged course of iodide of iron. 



DISEASES OF THE SCLEROTIC AND CHOROID. 



STAPHYLOMA POSTICUM (SCLERECTASIA. SCLEROTICO- CHOROIDITIS 
POSTERIOR). 

Definition. — A conical protrusion backwards, of a portion of the 
sclerotic, in the neigh- 
bourhood of the optic 
nerve, usually on its 
outer side, involving the 
choroid and retina. 

Morbid Appearances. 
— A clear zone surround- 
ing the optic nerve (Fig. 
82), caused by removal 
of pigment from the 
atrophied choroid, which 
no longer prevents a 
view of the white scle- 
rotic behind. The zone 
grows whiter as the 
disease advances, and 
greyish streaks or spots 
are observed in it. At 
first the zone is incom- 
plete, and in the form of 
a crescent joined by its concave edge to the optic nerve. As the atrophy 




600 



DISEASES OF THE SCLEROTIC AND CHOROID. 



of the choroid proceeds farther outwards, the white or mottled zone 

spreads in a more or less circular form. (Fig. 84.) 

In more advanced stages the circular outline is lost, the atrophied 

choroid extending into rounded or oblong processes. (Fig. 83.) 

The white crescen- 
Fig. 83. tic figure so character- 

istic of this disease is 
the inner surface of 
the protruded sclero- 
tic. When the sta- 
phyloma is deep, the 
adjacent portion of 
the sclero-choroidal 
ring bounding the 
optic nerve is obliter- 
ated, and the corre- 
sponding side of the 
optic nerve entrance 
is pulled down into 
the hollow. When 
this has happeued the 
nerve entrance is seen 
in perspective, and 
its figure is conse- 
quently elliptical in 
proportion as it slopes 
into the hollow. 
When the staphy- 
loma is to the side of 
the optic nerve, the 
major axis of the 
ellipse will of course 
be vertical. This con- 
dition is well repre- 
sented in Fig. 83. 

Symptom, — Pos- 
teiior staphyloma is 
the most frequent 
cause of myopia 
(short sight). When 
the yellow spot be- 
comes involved in the 
disease amblyopia re- 
sults. 

Diagnosis. — The 
white crescentic 
figure near the optic 

nerve ; unusual distinctness of the retinal vessels ramifying in front 

of a white ground ; and their undulatory course from the nerve en- 




Fisc. 84. 




DISEASES OF THE LENS. 601 

trance across the depression, are positive marks of posterior staphy- 
loma. 

Cause. — According to Von Ammon there exists in an early stage of 
foetal life a protuberance of the sclerotic on the outer side of the optic 
nerve which communicates with the anterior cerebral vesicle by means 
of an oval opening:. There is therefore a natural tendency to this de- 
fect, and a very slight accident or arrest of development may cause it. 
Atrophy of the choroid, resulting in wasting, and distension of the 
sclerotic, may produce it in after life. 

Treatment. — The defect of vision to be remedied by the use of con- 
cave glasses, of suitable power. 



DISEASES OF THE LENS. 

Every morbid process that affects the lens results in more or less 
irremediable opacity, and bears the name of " cataract." It is con- 
veniently divided into lenticular and capsular, according as it affects 
the lens and its capsule respectively. 

Congenital Cataract. — Four varieties. I. A minute chalky- 
white dot, deposited in the most superficial part of the lens within the 
capsule, and occupying the centre of a clear dark pupil (Cat. centralis). 
II. A more extensive deposit occupying nearly the whole area of the 
pupil ; it has a conical shape, with the apex directed forwards (C. pyra- 
midata). III. A greyish-white opacity composed of faint striae, termi- 
nating in a little opaque white dot. IV. Irregular fatty or earthy 
patches, affecting either the anterior or posterior surface of the capsule. 

These opacities are circumscribed, the rest of the lens remaining per- 
fectly clear : they do not extend, and when small do not prevent sight. 
When large they require surgical interference. They are diagnosed from 
diseases of deeper structures by their brilliant white colour and compa- 
ratively superficial position. Morbid deposits in the fundus of the eye 
have a yellow colour. Congenital cataract, as a rule, affects both eyes. The 
symptoms attendant upon these conditions are, more or less cloudiness of 
vision and inability to distinguish type ; but when the pupil is dilated 
with atropia, the most perfect and minute vision. 

Cataract in Adults and Old Persons. — Complete opacity ot 
lens, except from injury ; is rare before forty. After fifty it is the com- 
monest cause of failing sight. The hard variety spreads inwards from 
circumference to centre. Opaque streaks first appear at the extreme 
edge of the lens, which gradually coalesce into patches and spread in 
a radiating manner, first and chiefly over the posterior surface, and at 
a later period involving the anterior surface. After a year or more the 
whole lens becomes a little hazy, and opaque streaks begin to appear 
within the margin of the pupil, and converge to the central line of 
vision ; and slowly the pupil changes from black to milk-white, and 
the opacity is complete. In rare instances the opaque lens becomes 
deep-brown. 



602 GLAUCOMA. 

In the fluid form of cataract, no converging streaks are seen ; the 
morbid process is one of softening, which goes on till the whole lens 
becomes a white, bluish-white, or dirty grey pultaceous matter. 



GLAUCOMA. 

VARIETIES. — Acute and chronic. 

Definition.— Inflammation of the interior of the eye leading to effu- 
sion of fluid within the eyeball, and destructive distension. 

Symptoms. — These come on between the ages of fifty and sixty, and 
both eyes are usually affected. In the acute form the disease begins 
with sudden and violent pain in the eyeball and temple, followed by 
rapid extinction of vision ; the pupil is widely dilated, motionless, 
sometimes transversely oval, and of a greenish tint ; the iris bulges 
forward, and its veins are often distinctly enlarged ; the lens is hazy or 
even milky, and advanced almost to the posterior surface of the cornea ; 
cornea dull ; the sclerotic and conjunctiva behind the margin of the 
cornea are congested. The globe feels very hard, and is tender. 

The chronic form begins very insidiously; dimness of sight, dull 
aching pain in the eye or head, and fla>hes of light across the field of 
vision, sooner or later indicate the progress of internal disease. The 
patient becomes gradually blind, the pupil enlarged and insensible, and 
the eye ultimately assumes the appearances above described, but the 
distended globe is not painful on pressure. Chronic iritis and cataract 
appear sooner or later, and large dark purple veins show themselves on 
the sclerotic. 

When the eyeball is distended by effusion, the termination of the 
optic nerve losing the support of the sclerotic, is the first part to yield 
to the pressure, and, as it is pushed backwards, there is a corresponding 
depression of the optic disc. This condition is distinctly marked by 
the appearance of the blood-vessels in the optic disc and at its margins. 
At the bottom of the depression the main trunks are spread out, and 
appear smaller and quite unconnected with their larger prolongations 
at the margin of the excavation. By focussing the vessels at the bot- 
tom of the depression, and then gradually advancing the lens, so as to 
advance the focus, we may trace the continuity of the central and 
peripheral trunks, and, at the same time, measure approximately the 
depth of the depression. Extravasations of blood in the retina are very 
common. 

Cause. — Inflammation, probably commencing in the choroid. 

Prognosis. — Extremely unfavourable. 

Treatment. — Mercurial salivation does not appear to arrest the 
progress of the disease. In the acute form leeches, and subsequently 



SPECIFIC DISEASES OF THE EYE — AMAUROSIS. 603 

blisters, to the temples ; cold affusions to the head ; opium, ai:d quinine 
in full doses ; an occasional brisk purgative. 

The chronic disease has been much alleviated, and sight partially 
restored by extraction of the lens and excision of a portion of the iris. 

SPECIFIC DISEASES OF THE EYE. 

The internal tunics of the eye are often the seat of cancerous and 
tubercular deposits, and the lens, vitreous humour, and anterior and pos- 
terior chambers ai e sometimes occupied by parasites (Cystieercus tenui- 
collis, Filaria oculi, and Distomum ophthalmobium). It is important to 
be able to recognise a melanotic growth in the earliest stages of its exist- 
ence, in order that the eyeball may be extirpated, and the disease thus re- 
moved before it has involved other structures behind the globe. Dull pain, 
increasing dimness of vision, or dilated and sluggish pupil, a bright me- 
tallic reflection from the fundus, and the appearance of a vascular 
tumour projecting into the vitreous humour, are the symptoms of the 
disease. 

The diagnosis of cancer mainly rests on the presence of blood-vessels 
different in their arrangement, or distinct from those of the retina. But 
medullary and melanotic cancer often have their seat in the choroid, and 
then the retina is pushed forwards and the ophthalmoscopic indications 
are not diagnostic. 

Tubercular deposit forms a bright yellowish non-vascular tumour. 

Entozoa may be distinguished by their form and movements. 

AMATJKOSIS. GUTTA SERENA. 

Although this indefinite term is well-nigh obsolete, we may con- 
veniently use it here for the purpose of enumerating all causes of blind- 
ness, except those which are discoverable by the unaided eye, such as 
opacities of the cornea and lens. 

Amaurosis may be subdivided into two kinds : 1. Temporary or func- 
tional. 2. Permanent or organic. 

Temporary amaurosis is due to the following causes : — Exposure to 
intense light, loss of blood, diphtheria. 

Permanent amaurosis may be due either to interocular or to inter- 
cranial disease. In the former case it is caused by fatty degeneration 
of the retina, as in Bright 's disease ; retinitis ; retinal haemorrhage ; 
choroiditis with effusion of serum or blood, causing detachment of the 
letina; scrofulous or melanotic tumours, immediately behind or in 
front of the retina ; glaucoma. 

Intercranial amaurosis may be caused by pressure upon or atrophy of 
any portion of the optic nerves, or of those parts of the optic thalami 
and corpora geniculata in which they have their origin. 

The ophthalmoscope will generally enable us to discover the cause of 
the blindness. If the disease be intercranial, the optic nerve entrance 
will afford characteristic indications. (See Atrophy of Optic Disc, 
p. 596.) The treatment must be determined by the cause. 



604 DEFECTS OF THE REFRACTIVE MEDIA OF THE EYE. 



DEFECTS AXD DISPROPORTION OF THE REFRACTIVE MEDIA OF 
THE EYE. 

Such, defects as the following are very common ; and since some are 
remediable, while others occasionally give rise to alarm, it is necessary 
that the practitioner should be familiar with them. 

Astigmatism. — Under this title Donders, " Accommodation and Re- 
fraction," includes those phenomena which result from inequality of the 
refractive media. The error chiefly lies in the cornea itself, which, on 
account of variation in thickness or density, produces the same effect 
upon vision as an unsmooth pane of crown glass interposed between the 
eye and a distant object. The rays of light being unequally refracted 
as they pass through the several parts of the unequal cornea, straight 
lines cease to be parallel, but become zigzagged and broken, and circles 
lose the even outline ; — in a word, a straight line appears broken, and 
a circular spot unsymmetrical. 

Myopia. — Short sight. An inability to distinguish near objects at 
the usual distance from the eye. It is caused by undue convexity of 
the refracting media, whereby the image of an object held at the usual 
distance is brought to a focus at a point in front of the retina ; and in 
order to throw the image further back upon the retina, the object must 
be approximated to the eye. 

Anything which causes a prolongation of the visual axis must result 
in myopia. According to Liebreich, Donders, and others, posterior sta- 
phyloma (see p. 599) is the most frequent cause of this defect/ 

Myopia is remedied by the use of biconcave glasses of such a focus 
that distant objects shall appear distinct and undiminished in size. 

Presbyopia. — Old or long sight. Inability to discern near objects. 
This is caused by unduly small convexity of the refracting media, where- 
by the image of an object held at the usual distance from the eye is 
brought to a focus at a point behind the retina, and in order to advance 
it, it is necessary to remove the object to an unusual distance. 

This defect is compensated by the use of biconvex glasses of suitable 
convexity. 

Muscle Volitantes. — Some persons are annoyed, and for a time 
alarmed, by minute dark specks or beaded filaments, which, by floating 
in front of the retinal image, puzzle and constantly threaten to obscure 
vision. " If the eye be directed towards a clear sky, and then kept 
steadily fixed, the spots appear to sink slowly downwards. A brisk move- 
ment of the eye instantly whisks the little bodies about in various direc- 
tions, and then as soon as the eye is steadied, they again slowly sail across 
the field of vision." (Dixon on Diseases of the Eye.) M'Kenzie supposes 
them to be shadows cast on the retina by minute bodies moving in front 
of, and almost in contact with, it. They are not symptomatic of any 
organic disease, and need not excite alarm. 



( 605 ) 



DISEASES OF THE EAR. 

1. Otitis Externa. . . Inflammation of the External Ear. 

2. Otitis Interna . . . Inflammation of the Internal Ear. 

3. Surditas ..... Deafness. 

OTITIS EXTERNA— INFLAMMATION OF THE 
EXTERNAL EAR. 

1. ACUTE INFLAMMATION OF THE EXTERNAL EAR. 

Symptoms. — Pain in the passage, gradually increasing, and aug- 
mented by cold, pressure, and the motions of the jaw ; deafness ; noises 
in the ear ; redness and swelling of the lining membrane ; and after an 
interval of a few hours, or one or two days, a thin acrid fcetid discharge, 
often tinged with blood, and becoming puriform. The inflammation is 
followed by enlargement of the mucous follicles, and terminates by sup- 
puration, ulceration, and the formation of scabs, or of painful granula- 
tions. 

Termination. — In resolution, or in the chronic form. 

Causes. — Predisposing. Childhood ; the scrofulous diathesis. — 
Exciting. Cold ; the introduction of foreign bodies into the ear ; 
the extension of inflammation from surrounding parts ; the exanthemata, 
especially scarlatina. 

Treatment. — Poultices and warm fomentations to the ear; the 
injection of warm water, alone or containing from five to ten grains of 
acetate of lead to the ounce ; in severe cases, leeches behind the ear, 
blisters over the mastoid process ; aperients. If an abscess form, poultices 
and warm fomentations, to promote suppuration and encourage the dis- 
charge. 

2. CHRONIC INFLAMMATION OF THE EXTERNAL EAR. 

Symptoms. — The same as in Acute Otitis ; but less severe. 

Treatment. — If the disease be still recent, and the acute stage have 
only partially subsided, injections of warm water, or of a weak solution 
of acetate of lead, should be used several times in the day, followed by 
stronger astringents, such as solutions of alum, sulphate of zinc, and 
nitrate of silver. If granulations of the mucous membrane have formed, 
tents of lint or cotton, dipped in zinc ointment, may be introduced into 
the meatus. The general treatment will consist in the steady use of 
aperients and alteratives, nourishing diet, pure air, and cleanliness; and 
if there be much debility, chalybeate tonics. If the discharge should 



(306 OTITIS INTERNA. 

suddenly cease, and symptoms of head affection occur, hot poultices and 
fomentations should be applied to the external ear, and the treatment 
for partial encephalitis adopted. 



OTITIS INTERNA— INFLAMMATION OF THE INTERNAL 

EAR. 

Varieties. — 1. Acute. 2. Chronic. 

1. ACUTE INFLAMMATION OF THE INTERNAL EAR. 






Symptoms. — Acute, deep-seated pain in the ear, and in the head and 
face of the same side, increased by mastication ; a sense of tension in 
the ear; loud noises; deafness; sometimes swelling of the tonsils, with 
dull pain or itching at the back of the throat. There is a frequent, 
quick, and hard pulse, hot skin, anxious countenance, furred tongue, 
anorexia, general febrile excitement, restlessness, sleeplessness, and, in 
very severe cases, delirium and convulsions. 

Terminations. — In resolution, with gradual subsidence of the 
symptoms. In suppuration, attended by throbbing pain and great ten- 
sion, followed by discharge of matter from the external meatus (the 
membrana tympani having been ruptured) through the Eustachian 
tube into the throat, or through an opening in the mastoid process. 

Causes. — Those of inflammation of the external ear ; the extension 
of inflammation from the throat through the Eustachian tube. 

Diagnosis. — From inflammation of the external ear by the deeper- 
seated pain, the absence of discharge from the external meatus in the 
early stage, and the results of an examination of the external ear. The 
rupture of the membrana tympani may be recognised by the speculum ; 
and if the patient expire forcibly, the mouth and nostrils being closed, 
air will issue from the ear. 

Prognosis. — Deafness is a very common consequence of this disease ; 
and inflammation of the dura mater, and other membranes of the brain, 
an occasional result. 

Treatment. — Bleeding, followed by cupping or leeches behind the 
ear, and counter- irritation, by blisters or tartar-emetic ointment ape- 
rients. If suppuration have taken place, and there be extreme tension, 
with throbbing pain in the ear, and violent headache and delirium, 
instantaneous relief may be afforded by puncturing the membrana 
tympani, washing the ear out repeatedly with tepid water, and facili- 
tating the discharge of matter, by causing the patient to lie on the 
affected side. If theie be swelling or inflammation in the fauces, astrin- 
gent gargles should be used, or the steam of warm water inhaled. If 
there be rea-on to believe that the Eustachian tube is obstructed, the air- 
douche or the ear-catheter may be employed. 



DEAFNESS. 607 



2. CHRONIC INFLAMMATION OF THE INTERNAL EAR. 

Symptoms. — The principal symptom of chronic inflammation of the 
ear, whether external or internal, is a discharge of mucus, muco-purulent, 
or purulent matter (otorrhoea), from the external meatus, with deafness 
more or less complete. 

Terminations. — In caries of the temporal bone ; destruction of the 
bones of the ear ; or permanent deafness ; partial encephalitis. 

Treatment. — The same as in chronic inflammation of the. external 
ear, combined with the use of gargles, the air-douche, or the ear-catheter. 
The purely medical treatment will be regulated by the existing state of 
the constitution. If it be connected with scrofula or syphilis, the 
remedies proper to those diseases ; if combined with skin diseases affecting 
the head and face, the remedies required by the particular form of skin 
disease; if with a deranged state of the digestive organs, aperients and 
alteratives. Wholesome diet, cleanliness, puie air, proper exercise, and 
a strict attention to the state of the bowels, with tonics and alteratives, 
ai e requisite in all forms of the disease. 



SURDIT AS— -DEAFNESS. 



Causes. — Congenital absence, or excessive contraction of the external 
meatus. Accumulation of wax ; inflammation and swelling of the 
meatus ; mucous tumours (polypi) ; osseous tumours ; foreign bodies, 
such as wool and hairs in the meatus. Inflammation, calcareous de- 
generation, and destruction or extreme relaxation of the membrana 
tvmpani. All these causes are readily observed, and the treatment is 
obvious. The following causes are more obscure : — inflammatory thick- 
ening of the Eustachian tube at its faucial orifice ; also at its tympanic 
orifice ; collections of pus, mucus, or blood in the tympanum ; anchylosis 
of the ossicula. Diseases affecting the auditory nerve generally implicate 
the portio dura, and facial palsy of one side results. 

Functional deafness may result from concussion, sudden and loud 
noises, poisons, e. g. aconite, typhus fever, diphtheria. 



( 608 ) 



CHAPTER VIII. 

CUTANEOUS DISEASES. 

CLASSES. 
1. PARASITICAL. 2. NON-PARASITICAL. 

PARASITICAL. 

Orders. 

1. Dermatozoa Animal Parasites. 

2. Derimatophyta .... Vegetable Parasites. 

NON-PARASITICAL. 

Orders. 

1. Exanthemata .... Rashes. 

2. Vesicul.£ Vesicles. 

3. Bullae Blebs. 

4. Pustule Pustules. 

5. Papula Pimples. 

6. Squama Scales. 

7. TcBERCULiE Tubercles. 

8. Maculae Spots. 

GENERAL OBSERVATIONS ON CUTANEOUS DISEASES. 

In order to take a just and comprehensive view of diseases of the skin, 
the complexity of its structure and function must be duly considered. 
It forms a most extensive vascular and exhalent surface, the nature and 
functions of which bring it into direct reciprocal relation both with the 
lungs and the kidneys. It has a proper glandular apparatus — the 
sebaceous. It contains the organ of touch, and is the seat of common 
sensation. It is furnished with hairs and nails, which share every de- 
rangement of the pail of the skin to which they are attached, and of 
which they are but modified processes. A surface so richly supplied 
with blood-vessels, nerves, and glands, must necessarily be very liable to 
derangement from variations of such external influences as temperature 
and moisture; and while its vascular suiface sympathises with every 



CUTANEOUS DISEASES — DEFINITIONS. 609 

derangement of the circulation in the internal organs, its protective 
cellular covering, and glandular orifices, are exposed to the invasions of 
parasites. 

At present the classification of cutaneous affections is extremely im- 
perfect, but as our knowledge of them increases we shall be able to 
form a simpler and more rational classification. In this work some- 
thing has been done towards the attainment of this object by making 
the diseases due to parasites a separate class, subdivided into two 
orders. 

The subdivision adopted for the other orders is convenient ; but it 
must be borne in mind that there are no abrupt lines of demarcation 
between them. An exanthem may pass through the successive stages 
of papule, vesicle, pustule, and squama in the natural sequence of 
morbid action and without any new exciting cause. 

Two diseases must be placed by themselves, as not admitting of classi- 
fication ; — lupus, furuncle. 

DEFINITIONS. 

1. Exanthemata. Bashes. — Superficial red patches, variously shaped, 
circumscribed, or diffused, disappearing on pressure, and terminating by 
resolution, deletescence, or desquamation. 

2. Vesiculce. Vesicles. — Small, round, pointed elevations of the 
cuticle, containing a colourless, transparent, or opaque, pearly lymph. 
They break and discharge their contents, and are succeeded by scurf, 
scales, or sores. Sometimes their contents are absorbed. 

3. Bulla?. Blebs. — Vesicles of larger size. 

4. Pustular. Pustules. — Circumscribed elevations of the cuticle, 
containing pus, and terminating in thick crusts or scabs. 

5. Papulce. Pimples. — Small, firm, pointed elevations of the skin, 
usually terminating in scurf ; rarely by ulceration of the summit. 

6. Squamar. Scales. — Hard, opaque layers of cuticle, covering pa- 
pulae or inflamed surfaces ; continually detached and renewed. 

7. Tubercular. Tubercles. — Small, hard, persistent tumours of the 
skin, larger than papulae, with or without an inflamed base, and ter- 
minating in resolution, partial suppuration, or ulceration. 

8. Macular. Spots. — Permanent discolorations, or decolorations, of 
the skin, often accompanied by change of structure. 



( 610 ) 



PARASITICAL SKIN DISEASES. 

Order I. 

DERMATOZO A— ANIMAL PARASITES. 

Acarus Scabiei . . . The Itch. 

ACARUS FOLLICULORUM. 

Phthyriasis .... Lousiness. 
Filaria Medinensis . . Guinea Worm. 

SCABIES. PSORA— THE ITCH. 

Symptoms. — The usual seat of this eruption is between the fingers, 
on the wrists, inside of the forearm, and at the bends of the joints ; 
but it may affect any part of the body. It generally makes its ap- 
pearance a few days after exposure to the contagion, and is preceded 
tor one or two days by itching, increased towards evening and at night, 
and by all causes which excite the circulation. The eruption consists 
either of pale rose-coloured or greyish pimples, or of pointed vesicles, 
containing serum, raised slightly above the surface. In severe cases 
these vesicles enlarge, and become filled with pus (Scabies puiulenta), 
or they are destroyed by friction, and leave small round dark spots. 
The pimples or vesicles are either single or in small groups ; rarely in 
patches of any size. The disease is accompanied throughout by most 
distressing itching. 

Causes. — Predisposing. Neglect of personal cleanliness. — Exciting. 
Contagion; the acarus (Sarcoptes, Cheyletes) scabiei. (Fig. 85.) Half 
an hour after it is placed on the skin it 
bores perpendicularly through the cuticle, 
and then obliquely through the softer cells 
beneath to the cutis, in a little circular de- 
pression of which it lodges itself. 

Diagnosis. — The vesicular and pustu- 
lar forms of scabies are distinguished by 
a little black line which can usually be 
traced from the centre of the itch vesicle 
outwards for a short distance. This is the 
tunnel formed by the acarus. When scabies 
assumes the papular form, and the summits 
of the pimples are scratched off, so as to 
leave round dark spots, it is difficult to dis- 
tinguish from Prurigo senilis. Advanced 
age affords a probability in favour of the 
latter; while the fact of more than one 
member of the same family being affected, is conclusive as to the 
former. From lichen, by the latter being papular, more clustered, 
and, if situated on the hand, being on the back, and not between the 



Fig. 85. 




ACAEUS FOLLICULORUM — PHTHYRIASIS. 



611 



fingers. From herpes and eczema, by the vesicles "being more isolated, 
and in smaller clusters, by the intense itching and by their contagious 
nature, and often by their situation. Scabies very rarely attacks the 
face. 

Treatment. — Sulphur ointment, or an ointment of sulphur and 
carbonate of potash ; sulphur baths ; sulphuret of lime, with olive oil ; 
a strong alcoholic solution of stavesacre. Cleanliness and the warm 
bath, and gentle aperients if required, are useful auxiliaries. 



ACARUS FOLLICULORUM. 



Synonym. — Demodex folliculorum. Steazoon folliculorum. 

This parasite (Fig. 86) was discovered by Henle and 
Gustave Simon in 1842. Some observers state that it - 
may be found in the sebaceous follicles of most persons. 
They occur sometimes singly, sometimes as many as thirteen 
in a follicle ; they usually occupy the duct near the orifice, 
towards which the abdomen is directed, the head lying 
deeper in the gland. 

According to Mr. Erasmus Wilson the animal varies in 
length from the ^ to the -^ of an inch. Much difference 
exists in the length and development of the abdomen. As 
represented in Fig. 86 it is much elongated. In the other 
varieties there are four pairs of legs, and the abdomen is 
shorter. 

Symptoms. — This parasite usually causes no disturbance, 
and appears to be compatible with a perfectly healthy state 
of the sebaceous follicles ; sometimes, however, it pro- 
duces pustular and indurated acne of rather an inveterate 
form. 

Treatment. — The follicles should be emptied by pres- 
sure, and unguentum sulphuris, or a solution of sulphur and 
camphor in spirit of turpentine, rubbed in. 



PHTHYRIASIS— LOUSINESS. 

Three species of louse take up their abode on the human body. They 
are the following : — Fediculus capitis, P. corporis, and P. pubis. 

Symptoms. — They run about and bite the skin, producing intolerable 
itching, and occasionally pustular eruptions; their eggs (popularly 
called nits) are readily observed attached to the hairs. 

Treatment. — Mercurial ointment, well rubbed in, is an effectual 
remedy against the P. pubis. The unguentum hydrargyri ammoniati 
is equally efficacious against the other two species. 



( 612 ) 



FILARIA MEDINEXSI3— GUINEA-WORM. 

Synonyms. — Dracunculus. Hair-worm. 

Symptoms. — An itching is felt in the skin of some part of the 
arms or legs ; most frequently in the lower extremities, and especially 
in the feet. This is soon followed by a small vesicle, succeeded by an 
indolent inflamed swelling like a boil, which breaks and discharges. 
The head of the worm gradually protrudes through the opening, so as 
to be easily seized ; but unskilful attempts to withdraw it are apt to 
be followed by acute inflammation, extensive suppuration, and, in some 
cases, mortification. 

Diagnosis. — The length of the worm varies from half a foot to 
twelve feet. Its form and size are shown in the subjoined engraving 

Fig. 87. 




(Fig. 87) of a worm extracted from the heel of a negro, and preserved 
in the Museum at King's College. The form of the tail is seen at a. 
The head is of a darker colour than the body. 

Causes. — Predisposing. The rainy seasons in the tropical regions 
of Asia, Africa, and especially Upper Egypt, Nubia, and Guinea. — 
Exciting. The worm in an embryo state pierces the skin (usually the 
feet, and hands), immersed in, or otherwise brought into contact with, 
the water which it inhabits. 



EPIDERMMYCOSIS VERSICOLOR. 613 

Treatment. — The worm must be cautiously and patiently ex- 
tracted, by rolling a fresh portion each day round a quill or roll of 
cotton, strapped in the intervals to the adjoining skin. Suppuration 
should be promoted by bread poultices. 

Prophylaxis. — When the disease prevails among bodies of men, 
separation from the sound, and scrupulous cleanliness. 



Order II. 
VEGETABLE PARASITES. 



*Epidermmycosis Versicolor . Chloasma. 

Epidermmycosis Decalvans . Baldness. 

Epidermmycosis Tonsurans . Ringworm of the Scalp. 

Dermmycosis Circinata . . Ringworm. 

Dermmycosis Sycosa . . . Chin VVelk. 

Dermmycosis Fayosa . . . Scall Head. 
Plica Polonica. 
Fungus Foot of India. 

EPIDERMMYCOSIS— MOULDINESS OF THE EPIDERMIS, AND 
DERMMYCOSIS— MOULDINESS OF THE SKIN. 

Under these generic terms are included all diseases of the skin and 
its appendages, which are known to be due to vegetable parasites. 

The confusion in the nomenclature of skin diseases is so complete, 
that an apology for employing new terms which are at once significant 
and descriptive is scarcely needed. In applying these new terms, we 
shall associate them with the names in common use, in order that the 
diseases to which these refer may be the more readily recognised. 



EPIDERMMYCOSIS VERSICOLOR. 

Synonyms. — Pityriasis versicolor, et rubra. Chloasma, Pannus 
hepaticus. Liver spots. 

Symptoms. — Delicate pinkish, greyish, or light yellowish -brown 
spots, varying in diameter from the |th of an inch to an inch or more, 
in the axillary, pubic, and inguinal regions, gradually extending and 
becoming confluent, so as to form continuous patches with sinuous 
margins, covering the greater part of the chest, abdomen, and shoulders, 
leaving here and there a small island of healthy skin. Its favourite 
seat is under the hairs about the pubes. It never affects parts exposed 
to the light. The colour varies much : in most persons of dark com- 

* See Glossary. 



614 



EPLDERMMYCOSIS VERSICOLOR. 



plexions, it has a light dirty-brown colour, and is separated from the 
surrounding healthy skin by a sharply-defined line ; in others the 
colour is fainter, and resembles that of a sunburnt face. Occasionally 
only a few small circles of skin are unaffected, forming, perhaps, a 
single cluster, not larger than the hand, on some part of the trunk. 
The hue of the diseased skin corresponds so closely to that of the ex- 
posed parts of the body that I have known the few pearl-like spots of 
healthy skin to be mistaken, under the name of albinism, for the dis- 
eased skin. 

Usually there is no breach of surface, and the disease is apparently 
nothing more than a spreading discoloration ; but on examining the 
discoloured skin attentively, the cuticle is observed to be minutely 
wrinkled, and on scraping it with a scalpel we find that the discoloured 
portions may be separated as minute silvery scales, whereas the healthy 
cuticle is not readily detached. 

The disease being entirely confined to the epidermis, is unaccompanied 
by irritation ; so that in some cases, when the patient's attention is first 
called to it, he doubts whether or not the discoloration is congenital. 
When the disease is of long standing, the cuticle becomes loose, and 
a minute silvery desquamation takes place continuously. 

Cause. — A fungus, called Mycrosporon furfur, composed of minute 
ointed filaments forming a close network among the cells of the cuticle, 
and developing vast numbers of bright 
spherical, nearly equal-sized spores, in 
patches of various sizes. (Fig. 88.) 

Contagion. — The fungus may be easily 
transplanted to the healthy skin by lying 
\^J&=^'^=^^^^T^~~ between sheets previously used by one 

affected with the disease. The fungus never 
attacks persons before the age of puberty. 
According to my own observations it is 
more frequently found in men than in 
women, and in those who lead a dissolute 
life. Kobust health and cleanliness confer 
no protection whatever. The gentleman 
from whom the specimen delineated in Fig. 
88 was obtained, was of the most scru- 
pulously cleanly habits ; yet the disease 
spread unchecked for two years. Indeed 
daily baths appear to facilitate its develop- 
ment. 
Diagnosis. — The characteristic appearance under the microscope. 
The cuticle should be scraped off with a scalpel, placed on a glass slide, 
and wetted with weak solution of ammonia, which renders the cuticular 
cells transparent. So minute is the fungus, that a i object-glass, at 
least, is necessary. Epidermmycosis versicolor is frequently mistaken 
for syphilitic eruptions, and the patient subjected to treatment accord- 
ingly. 



Fig. 83. 




EPIDERMMYCOSIS TONSURANS. 



615 



Treatment. — Solution of chloride of mercury (gr. i-iii to fjj); 
or hyposulphite of soda (gr. xxx to fjj) ; or sulphurous acid daily 
applied to the skin. The disease rapidly yields, an t the skin resumes 
its healthy colour under this treatment. 



EPIDERMMYCOSIS DECALVANS. 

Synonyms. — Porrigo decalvans. Alopecia. Phyto-alopecia. 

Definition. — Mouldiness of che roots of the hair, resulting in 
baldness. 

Symptoms. — The hair becomes dry, withered, and faded ; falls off, 
and is not regenerated, leaving more or less circular patches of smooth, 
apparently healthy skin. The disease may spread over the whole 
surface, and entirely deprive the body of hair. 

Cause and Pathology. — The development of the fungus Micro- 
sporon Audouini in the roots of the hair, within the follicles, and for a 
little distance beyond. The plant is composed of minute round and 
oval spores, and short branched filaments. It forms a uniform layer round 
the roots of the hair, and invades the cuticle and cortex, rendering the 
hair opaque and brittle. The plant develops very rapidly. 

Contagion. — The disease is readily communicated by the spores of 
the fungus. 

Treatment. — That recommended for Epidermmycosis versicolor. 



EPIDERMMYCOSIS TONSURANS— RINGWORM OF THE 
SCALP. 



Herpes tondens. Trichosis fmfu- 
Fig. 89. 



Synonyms. — Porrigo scutulata 
rans. Rhizo-phyto-alopecia. 

Definition. — Mouldiness of the roots of the hairs 
of the head, resulting in their breaking away nearly on 
a level with the surface of the skin. 

Symptoms. — The hairs are thickened, bent at their 
junction with the skin, have a withered appearance, 
become very brittle at the roots, and ultimately break 
off at a distance of one or two lines from the surface. 
The stumps present a ragged, split appearance, and 
readily break if an attempt be made to remove them 
from the follicle. The disease affects the hair in dry, 
scaly, circular patches, varying from half an inch to 
four inches in diameter. The contiguous cuticle shar- 
ing in the disease, and forming characteristic scaly 
fringes round the orifices of the hair follicles. Vesicles 
and dry scabs are occasionally formed during the pro- 
gress of the disease. 




616 DERMMYCOSIS C1RCINATA — DERMMYCOSIS SYCOSA. 

Cause and Pathology. — The roots of the hairs are found to be 
completely pervaded and split up by the Tricophyton tonsurans 
(Fig. 89 ), a fungus composed of minute round or oval spores, destitute 
of granules, and short curved filaments. 

Contagion. — The disease is readily communicated by the spores. 

Treatment. — That recommendel for Epidermmycosis versicolor. 



DERMMYCOSIS CIRCINATA— RINGWORM. 

Synonyms. — Tinea circinata. Herpes circinatus. 

Definition. — Mouldiness of the skin, chiefly of the epidermis, 
spreading in the form of rings. 

Symptoms. — At first a number of very small vesicles arranged in 
circles on a red, inflamed base. The breadth of the ring formed by the 
vesicles is usually about a quarter of an inch ; the base itself varying 
from a few lines to one or two inches. The vesicles crack, and the 
secretion dries and forms scales which are readily detached. External 
to these scales a fresh ring of vesicles is developed, which also become 
converted into scales, and thus the process goes on, the patch constantly 
widening by centrifugal growth, and leaving the parts previously 
affected in a chronically inflamed and dry scaly condition. The disease 
chiefly attacks the young, and usually appears on the face, neck, chest, 
and arms. When it affects the scalp it takes on the same form and 
produces the same effect as Epidermmycosis tonsurans, with which it is 
piobably identical. The disease is highly contagious. 

The cause, r inode of propagation, and treatment, are those described 
under Epidermmycosis tonsurans. 



DERMMYCOSIS SYCOSA. 



Synonyms. — Hentagra. Tinea sycosa. Sycosis menti. Mentagro- 
phyte. Chin Welk. 

Symptoms. — Redness, tension and smarting of the skin of the chin, 
lower jaw, or upper lip, followed by an eruption of small red points, 
which, in a day or two, ripen into distinct pointed pustules, traversed 
by a single hair. After five or six days more, the pustules discharge 
their contents, and form thin brownish scabs, which fall off, and ^are 
sometimes not renewed, the disease terminating in from ten days to a 
fortnight ; but usually successive crops are developed, and in extreme 
cases, the skin is covered with a thick, yellowish- brown crust, in which 
the hairs are matted. When the disease has continued some time the 



DERMMYC0SIS FAVOSA. 



617 



In chronic cases, the skin of the parts affected is covered 
The disease may attack 



beard falls off, 

with tubercles 

any part where the hairs are strong. It is 

often very obstinate. 

Cause axd Pathology. — The disease 
is due to the development of the Microsporon 
mentagrophytes (Fig. 90), which invades 
the hair follicles and forms a sheath round 

the roots of the hairs. The fungus luxu- 
riates in the epithelial layer of the hair 
follicle, and sets up inflammation in the 
subjacent vascular parts. 

Diagnosis. — The spores are very minute, 
and the filaments branch at acute angles and 
are annulated. 

Treatment. — The hair should be re- 
moved from the affected follicles by pincers 
and a solution of corrosive sublimate (gr. x 
to f'Jj) should be applied with a camel hair 
brush. Epilation is usually easy and pain- 
less, for the tendency of the disease is to 
loosen the hair, 



Fig. 90, 




DERMMYCOSIS FAVOSA. 

Synonyms. — Favus. Tinea favosa, annularis, et rugosa. Porrigo 
lupinosa, et scutulata. Scall head. Honeycomb scall. 

Varieties. — Porrigo favosa ; porrigo scutulata ; porrigo decalvans. 

Symptoms. — Small round pustules, usually seated on the hairy scalp, 
and containing a yellow matter, which hardens into a prominent scab 
with a central depression (favus). The disease generally attacks chil- 
dren, but is not confined to them. The primary seat of the disease is in 
the hair follicles. 

It is not confined to the scalp, but may attack the chin, eyebrows, or 
forehead, and, in rare instances, the trunk or extremities. The scabs 
have an offensive mousy odour. When the pustules are closely set, the 
yellow crusts become confluent, and present a honeycombed appearance. 
If few pustules only appear, and their development be not interfered with, 
the favi become greatly enlarged, sometimes to the diameter of 1 J inch ; 
and form circular, yellow, dry elevations, depressed in the centre, and 
with smooth, rounded, varnished margins. These large crusts may be- 
come confluent, and then form the variety known as Porrigo lupinosa. 
When the disease is of some duration, it may be seen at the same time 
in all its stages — the red patches, the cluster of yellow pustules, crusts 
of various thickness, and bald spots. If the scabs be removed by 
poultices, the favi are reproduced on the clean raw surface. When the 



618 



PLICA POLONICA. 



disease disappears, the hair is slowly reproduced, but sometimes there is 
permanent baldness. The nails are occasionally affected. 

Causes and Pathology. — The disease is due to the development 
of the Anchorion Schonleinii (Fig. 91), in the deeper layers of the epider- 
mis, and on the surface of the 
Fig. 91. cutis. At first the deeper epi- 

thelial cells are disturbed, and 
the cuticle, and subsequently 
the whole epidermis, becomes 
raised, in a cncular, yellowish- 
white spot, which increases iu 
size, assumes a sulphur yellow 
colour, and becomes a favus. 
When, as is commonly the case, 
the parasite attacks the hair 
follicles, the depressed centre of 
each favus is occupied by a 
hair, which becomes thickened, 
opaque, non-elastic, and may 
readily be removed. When the 
crusts are removed, soaked in 
ammonia, and examined, they 
are found to be chiefly composed 
of the spores and large-jointed 
spore containing filaments of 
the fungus. 

Diagnosis. — The presence of 
the fungus distinguishes the disease from eczema and impetigo ; and 
the scabs of eczema have never the characteristic alveolar depressions. 
The pustules of impetigo are prominent and convex, seated on an in- 
flamed base, and the purulent contents have no trace of fungi. 

Prognosis. — The disease is often obstinate and of long duration. 

Treatment. — The hair must be cut close with sharp scissors, and 
well washed, and the scabs must be softened with warm fomentations or 
poultices. The best local application is the iodide of sulphur ointment ; 
or a saturated solution of sulphurous acid may be used. 




PLICA POLOXICA. 

A disease of the hair allied to the present class, but almost unknown 
in this country. It consists in an inflamed and tender state of the scalp, 
and a swollen condition of the hairs which are glued together into a 
compact mass by a viscid and offensive secretion. Two parasitic plants 
— the Tricophyton tonsurans and Tricophyton sporuloides— are said to 
accompany it, and are thought to be the cause of it. Nothing is known 






FUNGUS FOOT OF INDIA. 



619 



of the proper treatment, but the disease seems to be aggravated by cut- 
ting the hair. The best chance of cure would seem to be afforded by 
the application in the form of vapour of such stimulants as the mixed 
vapour of iodine and sulphur. 



FUNGUS FOOT OF INDIA. 

Synonyms. — Madura foot. Podelkoma. Mycetoma. Ghootloo. Mah- 
deo. Kirudeo. Dr. H. V. Carter, of Bombay, has given a full descrip- 
tion of this disease, and an elucidation of its cause, in the Trans, of the 
Medical and Physical Society of Bombay, 1860. The following is a 
brief summary of the principal facts : — 

Symptoms and Pathology. — The disease appears as a flattened 
swelling of the integument, from which the cuticle is thrown off, leaving 
a white surface, which presents numerous pinkish spots, and on making 
sections of the cutis these are found to be the extremities of pink, red, 
or orange-brown streaks radiating through the corium. This deposit is 
composed of minute bright globules, measuring -^ to ^^ of an inch in 
diameter. Occasionally, spherical groups 
of spores are seen. After a time the Fig. 92.* 

whole foot becomes swollen, and greyish „ 

depressed spots appear, composed of a thin 
layer of cuticle, which finally ruptures 
and discloses the orifice of channels, allow- 
ing the passage of a probe for a greater 
or less distance. Numerous depressions 
and circular apertures form over the 
surface of the dorsum, sides, and heel 
of the foot ; they are large enough to 
admit a pea or a shot, and numbers of 
small round granules like fish-roe or 
poppy-seeds are discharged with an icho- 
rous offensive fluid from the orifices. 
The foot continues to enlarge, and be- 
comes much misshapen. The surface is 
riddled with numerous round holes of 
various sizes, leading to canals and cavi- 
ties which pervade all the textures of the 
foot, including the bones. The lower ends 
of the tibia and fibula are often excavated 
into numerous communicating cavities, 
some large enough to lodge a hazel nut. 

The sinuses and excavations are filled with mahogany-brown or pink 
granules. A section of the diseased foot presents great indistinctness of 

* b. A globular mass of the fungus, natural size. a. Another in section. 

c. A fourth part of a slightly magnified. 

d. Spherical granules from outer surface of b magnified ; e and /, beaded 
filaments and spores highly magnified. 




620 FUNGUS FOOT OF INDIA. 

parts, the tissues being everywhere excavated, changed, and in pi* 
infiltrated with the coloured granules. The disease attains its maxi- 
mum development in about four years. It may continue for twelve 
years. No acute pain attends its progress, but merely a deep-seate " 
aching. The health suffers considerably, and the patient becomes 
emaciated and weak. 

In one case the disease has been observed to attack the hand. 

Cause. — The development of a fungus, called by Mr. Berkeley, 
Chionyphe Carteri. It occurs in globular masses, varying in size from 
a pin's head to that of a bullet (a b c, Fig. 92), friable and black upon 
the surface, where they present numbers of minute tubercles (d). Sec- 
tions show a radiated arrangement (a). Minutely examined, they are 
found to be composed of radiating tubular fibres, which branch and 
unite towards the circumference (c). Near the surface they become 
beaded (e). Interspersed among these fibres are the spores (/). Dr. 
Carter believes that the fungus is introduced from without, the spores 
gaining admission through the orifices of the sweat ducts, or any slight 
abrasion of the surface. The disease has occasionally followed a prick 
from a thorn. Farm labourers between the ages of 1 7 and 50, who go 
about with their feet uncovered, are most liable to its attacks. 

Distribution. — The disease is endemic in the Bombay and Bengal 
Presidencies. " Kattiawar, Kutch, Gujerat, Sind, the Deccan, Lower 
Concan, are known localities in the former Presidency. Aden appears 
doubtful. On the Madras side, Guntoor, Bellary, Madura, and Cuddapah 
are well-known localities ; parts of Mysore, and, it is said, Trichinopoly." 
(Carter.) In the Bengal Presidency it appears to prevail around Sirsa, 
and patients come from Bicaneer, Bhawalpore, and Hissar. 

Treatment. — In the later stages, amputation of the foot is the only 
remedy. In the earlier ones, the application of a strong solution of 
corrosive sublimate or hyposulphite of soda. 



( 621 ) 

NON-PARASITICAL SKIN DISEASES. 
Order I. 
. EXANTHEMATA— RASHES. 



Rubeola . 

Scarlatina 

Erysipelas 

Erythema 

Urticaria 

Roseola . 



Measles (p. 316). 

Scarlet Fever (p. 319). 

St. Anthony's Fire (p. 273). 

Inflammatory Blush. 

Nettle-rash. 

Rose-rash. 



ERYTHEMA— INFLAMMATORY BLUSH. 

Symptoms. — Red patches of variable form and extent disappearing 
on pressure, with little or no swelling, heat, pain, or fever. Not con- 
tagious, nor attended with danger. 

Varieties. — 1. Erythema papulatum, occurring in young persons 
of both sexes, on the trunk and upper extremities, in small, round, and 
slightly-prominent patches, which disappear entirely in the course of a 
few days. — 2. Erythema tuberculatum, in which the patches are larger, 
more prominent, and moie permanent. — 3. Erythema nodosum, which 
occurs chiefly in children and young persons of both sexes, on the ex- 
tremities, especially the forepart of the leg, its form rounded or oval, 
its size varying from half an inch to an inch in diameter, at first slightly 
raised above the surface, but in a few days assuming the form of red, 
painful tumours. The tumour's disappear in from a week to a fortnight. 
It is generally preceded by debility. — i. Erythema centrifugum, ap- 
pearing mostly on the cheek, as small round raised patches, which 
gradually spread from a small pimple till they cover a considerable 
extent of surface. 

Terminations. — In resolution without desquamation, or with slight 
desquamation (E. fugax and E. laeve) ; or in a sero-purulent exsudation 
of a disagreeable odour (E. intertrigo). 

Causes. — Friction and pressure ; heat and cold ; acrid discharges, 
as those of coryza, leucorrhcea, or gonorrhoea, and the urine and fasces ; 
dentition ; dyspepsia ; tension of the skin, as in anasarca. 

Diagnosis. — From erysipelas, by the redness being lighter and more 
superficial, and the swelling less ; by the absence of heat and pain ; and 
by its milder character and more favourable termination. From roseola, 
by the peculiar rosy tint of the latter. From rubeola and scarlatina, by 
the semi-lunar patches of the first, and by the great extent and deep- 
red hue of the last. Also by the peculiar constitutional symptoms and 
contagious character of these diseases. 



622 URTICARIA. 

Prognosis.— Favourable. 

Treatment. — When idiopathic, these blotches disappear of them- 
selves, or yield to gentle aperients, the warm bath, and tonics. If 
symptomatic, the treatment is that of the primary disease. 

In Erythyma nodosum the menstrual function is usually disordered, 
and chalybeate tonics are required. 



URTICARIA— NETTLE-RASH. 

Varieties. — 1. Urticaria evanida. 2. Urticaria febrilis. 

1. URTICARIA EVANIDA. 

Symptoms. — An eruption resembling in appearance, and in the in- 
tolerable itching which attends it, the stinging of nettles. The spots 
often appear suddenly, especially if the skin be rubbed or scratched, and 
seldom last many hours, sometimes not many minutes, but vanish, to 
appear on another part. Sometimes the rash assumes the form of long 
wheals, as it* the part had been struck with a whip or cane. The 
swellings are always firm and solid, and contain no liquid. In some 
persons, the eruption lasts only a few days, in others many months or 
years, appearing and disappearing at intervals. The rash generally 
disappears in the daytime, to return in the evening, and is accompanied 
by slight feverishness. It terminates in desquamation. 

Causes. — Predisposing. Peculiar constitution. — Exciting. Hand- 
ling the leaves of the common nettle. Shell-fish ; mushrooms ; honey ; 
vinegar ; cucumbers ; salad. Strawberries and several other fruits and 
articles of diet will cause urticaria in certain persons ; also valerian, 
turpentine, and copaiba. 

Diagnosis. — By its close resemblance to the sting of the nettle, the 
itching that attends it, and its fugitive character. 

Prognosis. — It generally disappears under the use of simple reme- 
dies ; but may last for months or years. 

Treatment. — If caused by irritating food, an emetic, followed by 
a gentle aperient. In chronic cases, warm or vapour, alkaline or 
sulphur, baths ; with a strictly -regulated diet, aperients, and altera- 
tives. In obstinate cases, Fowler's solution (five or six drops three 
times a day). The smarting may be allayed by lotions of acetate of lead, 
or cyanide of potassium, or by the warm bath. 

2. URTICARIA EEBRILIS. 

Symptoms. — This is generally caused by some article of food which 
has disagreed with the patient. There is more or less fever or constitu- 
tional disturbance, followed by heat and tingling of the body ; and then 



EOSEOLA. 623 

by an eruption, beginning on the shoulders, loins, and inner surface ot 
the arms and thighs, and round the knees, consisting of irregularly- 
shaped pale blotches, surrounded by a deep-red border, but soon assuming 
a uniform deep-red colour, and attended by intense itching. The blotches 
appear and disappear several times, and gradually subside in a few days 
or a week. There is generally an increase of itching and smarting 
towards evening. The treatment is that of Urticaria evanida, but more 
active. After an emetic of ipecacuanha, a saline aperient (Form. 261). 



ROSEOLA— ROSE-RASH. 



Symptoms. — Slight febrile symptoms, succeeded by deep-red patches 
of various size and form, appearing on different parts of the body, and 
generally disappearing in one or two days, or a week. 

Varieties. — 1. Roseola infantilis. An eruption of numerous small, 
distinct, circular patches, of a deep rose-red colour, occurring in infants 
from dentition or intestinal irritation. — 2. Roseola estiva. T his form is 
most common in children and females. It is preceded by feverishness. 
The rash, which is of a deep-red colour, and attended with itching and 
pain, and sometimes with an inflamed throat, with some difficulty in 
swallowing, commonly appears between the third and seventh days on 
the face and neck, whence it rapidly spreads over the rest of the body. 
It lasts about three or four days, and then disappears. — 3. Roseola 
autumnalis is a less severe affection, occurring also chiefly in children, 
and presenting larger patches, seated mostly on the upper extremities. 
— 4. Roseola annulata, appearing, as the name implies, in rosy rings, 
enclosing a portion of healthy skin, and gradually spreading. The rash 
is most common on the belly, loins, buttocks, and thighs. It may be 
acute or chronic, and is generally dependent upon some disorder of the 
alimentary canal. 

Causes. — Teething ; irritation of the stomach and bowels ; drinking 
cold water when the body is heated ; severe exercise. The disease is 
sometimes epidemic ; it occasionally precedes the eruption of the small- 
pox, occasioning some difficulty in diagnosis. 

Diagnosis. — From measles and scarlet fever, by the mildness of the 
constitutional symptoms, and the absence of the catarrhal symptoms of 
the one, and the sore throat of the other. 

Prognosis. — A favourable termination in a few days or a w r eek. 

Treatment. — Saline aperients with small doses of tartar-emetic 
two or three times a day; and an occasional warm bath. 



( 624 ) 



Order II. 

VESICUUE— VESICLES. 

Varicella .... Chicken-pox (p. 315). 

Eczema Running Scall. 

Herpes Tetter. 

Miliaria Miliary Fever. 

ECZEMA— HUMID TETTER. 
Synonyms. — Running scall ; crusta lactea. 
Species. — 1. Acute. 2. Chronic. 

1. acute eczema. 

Symptoms. — An eruption of small slightly-raised vesicles, crowded 
together on broad irregular patches of bright-red skin, accompanied by 
severe tingling and smarting. The fluid in the vesicles soon becomes 
opaque and turbid, and, in four or five days, is discharged, and dries 
into thin yellowish-green scabs. Fresh vesicles form on the surrounding 
skin, w T hile the parts already affected are kept moist by constant exuda- 
tion. When the eruption is of some standing, the skin presents a highly- 
inflamed surface, studded with a large number of minute pores, covered 
with thin white membranes. Usual duration, from a week to a month. 

Varieties. — 1. Eczema simplex. A mild form, free from con- 
stitutional disturbance, mostly attacking women and young children on 
the arm and forearm, and between the fingers, generally terminating 
in resolution. — 2. Eczema ruhrum. The skin is inflamed, hot, and 
tense, of a bright-red colour, and covered with small vesicles surrounded 
by an inflamed areola. The rash generally terminates in about a week, 
with slight exfoliation of the cuticle ; but in more severe cases, the in- 
flammation increases, the vesicles coalesce, the contained serum becomes 
opaque, and at length escapes as an irritating fluid, w T hich forms loose 
thin incrustations, and these falling off, display a highly-inflamed sur- 
face. The disease either disappears in two or three weeks, the healing 
process beginning at the margins, or it becomes chronic. — 3. Eczema 
impetiginodes. In this form, the inflammation, which is still more 
acute and rapid in its progress, is accompanied by much swelling and 
tension, and some fever; and the contents of the vesicles becoming 
purulent dry into soft yellow scabs, which fall off, and are reproduced, 
displaying a red inflamed surface covered with an ichorous serum. It 
generally terminates in about a month, the skin gradually assuming a 
more healthy appearance ; or it runs into the chronic form. It is dis- 
tinguished from impetigo by being at first vesicular, whereas impetigo 
is a pustular disease from the beginning ; and by the thinner scabs. 

Causes. — Predisjiosing. The female sex ; the seasons of spring 
and autumn. — Exciting. Intense heat ; the irritation of blisters 



CHKONIC ECZEMA. 625 

frictions with mercury {eczema mercuriale) ; the handling of dry- 
powders, flour, metals, &c. Contagion (?) 

Diagnosis. — An abundance of watery vesicles with tenderness and 
smarting distinguish eczema from scabies. Miliaria is accompanied 
by fever and profuse perspiration. Lichen is papular. Psoriasis is 
diy and scaly. 

Prognosis. — Favourable, but often difficult of cure. 

Treatment. — The mineral acids internally administered, cooling 
drinks, simple diet, warm baths, water-dressing, local baths of linseed, 
marsh-mallow or bran, or poultices of potato-flour. The distressing 
tingling and smarting may be relieved by decoction of poppy-heads, or 
by a lotion consisting of two grains of cyanide of potassium, to an ounce 
of water. Alkaline lotions, and zinc or chalk applications, are often of 
much service. 

chronic eczema. 

Symptoms. — This is a sequel of the acute form, and often intrac- 
table. The skin, from the continued abundant discharge of acrid serum 
and the reproduction of the vesicles, is highly inflamed and marked by 
fissures at the joints. Sometimes there is but little moisture, and the 
surface is cracked and covered with shining crusts, beneath which the 
skin is of a bright-red colour. The disease often spreads from a small 
point over a considerable extent of surface, and is accompanied by in- 
tense itching and smarting, which is particularly distressing when the 
eruption occupies the inner surface of the thighs, the verge of the anus, 
or the vulva. When it attacks the face, the conjunctiva of the eye is 
involved, and there is much smarting, with some intolerance of light. 
The eruption often lasts for years, being heightened and renewed in 
spring and autumn ; and sometimes, after the resources of art and the 
patience of the sufferer are exhausted, rapidly disappears. 

Causes. — Predisposing. Obscure. — Exciting. Intestinal irrita- 
tion ; painful dentition ; dysmenorrhcea. 

Treatment. — Mineral acids administered internally and with one 
of the bitter infusions, alkaline lotions externally. An alterative 
aperient should be given at bed-time occasionally. In obstinate cases 
"n\iii to XX\v of liquor arsenicalis may be prescribed. The sulphur 
bath (Form. 335) may be used with advantage. The itching- and 
smarting are best allayed by the zinc ointment mixed with spirits of 
wine (ung. zinci ^i, spt. vin. rect. 31) smeared over the surface, and 
renewed once or twice a day ; or by simple cold-water dressing. A 
handkerchief, moistened with a teaspoonful of chloroform, placed near 
the seat of irritation, and covered with the bed clothes, often allays 
the smarting. A solution of nitrate of silver (ten grains to the ounce) 
will also sometimes afford great relief. (G.) 



2 s 



( 626 ) 



HERPES— TETTER. 

Symptoms. — The rash begins as circumscribed groups of distinct 
vesicles on an inflamed base ; but these soon coalesce, and their con- 
tents, which were at first watery, become yellowish-white or yellow, 
escape and form a scab. This soon tails off, leaving an inflamed surface, 
which rapidly heals. The eruption is commonly preceded by slight 
constitutional symptoms, and sometimes by acute darting pain, which, 
when the eruption has made its appearance, changes to heat and smart- 
ing. The disease is rarely attended with danger, and generally lasts 
about a week or ten days. 

Varieties. — 1 . Herpes phlyctenodes, that which has no particular 
seat. — 2. Herpes tibialis, that which affects the lips. It may extend 
to the nose, cheeks, and chin ; it also attacks the mucous membrane of 
the lips and mouth. It is a very common accompaniment of catarrh, 
and of inflammatory affections of the mucous membrane of the mouth, 
throat, and stomach ; and it often appears during an attack of pneu- 
monia and ague, and concludes an attack of relapsing fever. — 3. Herpes 
preputiaiis attacks the internal or external surface of the prepuce, and 
is preceded and accompanied by itching and smarting. It is easily dis- 
tinguished from syphilis when recent, and afterwards by its history. 
The sore remaining atter the vesicles have burst is superficial, and 
readily heals if the two surfaces of the prepuce be separated with lint. 
— 4. Herpes zoster, zona, or the shingles, is very characteristic in its 
appearance, position, and course. As the name implies, it surrounds 
the body like a zone or girdle, beginning somewhere about the mesial 
line, and travelling round one-half of the body, following the direction 
of the intercostal nerves, below the nipple, at the lower part of the 
back and groin, or at the upper part of the thigh. It is often preceded 
for several days, or even longer, by very acute darting pains. It runs 
a mild course, and disappears in two or three weeks. — 5. Herpes iris. 
A very rare variety, consisting of four rings of different shades of 
colour. 

Causes. — Predisposing. An east wind. — Exciting. Catarrh; in- 
flammation of the mucous membranes ; indigestion. 

Diagnosis. — From pemphigus, by the smaller size and greater 
number of the vesicles. From eczema, by the larger size of the 
vesicles, the raised inflammatory base, and, generally, by the smaller 
size of the patches. 

Prognosis. — Favourable. The disease lasts from a week or ten 
days to a month, and in rare cases longer. 

Treatment. — Gentle aperients with antimonials, a regulated diet, 
and local applications of warm mucilaginous liquids. The constitu- 
tional treatment must be determined by the age and state of system. 






X 627 ) 



MILIARIA— MILIARY FEVER. 

Symptoms. — This disease sets in with rigors, extreme debility, de- 
pression of spirits, and a sense of* tightness and oppression about the 
praecordia, with shortness of breath, and, in some instances, a teasing 
cough, followed by increased heat of surface, with wanderiDg pains 
and restlessness. After these symptoms have continued from two to 
five or six days, a profuse sweat, of a sour, rank odour, makes its ap- 
pearance, accompanied by a harassing pricking or itching of the skin. 
On an uncertain day, a number of small red or white papulae, about 
the size of millet-seeds, perceptible to the touch, are observed first on 
the neck and breast, whence they gradually extend to the trunk and 
extremities. After ten or twelve hours, a small vesicle appeal's on the 
top of each pimple. The contents of the vesicles are at first trans- 
parent, but afterwards become white ; and they have a peculiarly offen- 
sive odour. In two or three days the vesicles break, and are succeeded 
by small crusts, which fall off in scales ; or the disease terminates in 
resolution, or by desquamation. The febrile symptoms do not subside 
on the appearance of the eruption, but after a variable interval. 

Causes. — Predisposing. Lax habit of body ; childhood ; old age ; 
the female sex ; the period of childbirth ; debility, however induced, 
and especially that arising from excessive discharges ; dyspepsia. — Ex- 
citing. Immoderate sweating, produced by excessive heat, or by heat- 
ing medicines. 

Diagnosis. — By the vmcommon anxiety and dejection of mind ; the 
profuse sweating, and the peculiarly foetid, rank odour of the perspira- 
tion. Afterwards, the characteristic appearance of the eruption. 

Prognosis. — Favourable. The fever assuming a mild form, and 
remitting on the appearance of the eruption ; the papulee of a florid 
red colour. — Unfavourable. The persistence of the sweating, with in- 
crease of fever after the appearance of the rash ; great anxiety and de- 
pression of spirits ; profound coma ; the sudden disappearance of the 
eruption, followed by great prostration of strength, anxiety, shortness 
of breath, rapid, weak, and intermitting pulse, violent vomiting, deli- 
rium, and convulsions ; the appearance of petechia? interspersed among 
the papulag ; anasarcous swellings. 

Treatment. — The temperature of the apartment should be mode* 
rated, and the patient lightly covered. After the bowels have been 
relieved by an aloetic purge, sulphuric acid with bark or quinine should 
be given. If there be much restlessness, opium. 



( 628 ) 

Order III. 

BULUE— BLEBS. 

Pemphigus . . . Vesicular Fever. 
Eupia .... Atonic Ulcer. 

PEMPHIGUS— VESICULAR FEVER. 

SYNONYMS. — Bullae; phlyctena; pompholix ; hydatis ; febris bul- 
losa ; febris vesicularis. 

Symptoms. — The rash is ushered in by the usual symptoms of the 
cold stage of fever ; lassitude, headache, sickness, oppression, frequent 
pulse, and, in some instances, delirium. On an uncertain day an erup- 
tion takes place of red circular patches, which soon terminate in pellucid 
blisters, similar to those produced by a burn, resting on an inflamed 
areola, and distended with a straw-coloured serum. They appear on 
the face, neck, trunk, arms, mouth, and fauces, and measure half an 
inch or more in diameter. In a few days the blisters either break and 
discharge a yellowish, bland, or sharp ichorous fluid, or they begin to 
shrink, and in a short time disappear. 

Varieties. — 1. Pemphigus infantlis attacks young infants in lying- 
in hospitals. It has been mistaken for syphilis. — 2. Pompiholix soli- 
tarius is characterised by the appearance of a single bleb at a time, on 
successive days, or at short intervals. — 3. Pompholix diutinus is a 
chronic disease, occurring, for the most part, in middle-aged and old 
men, lasting for a considerable time, and sometimes extending over the 
entire body. 

Causes. — Predisposing. The male sex ; adult and old age ; summer 
season. — Exciting. Unwholesome and scanty food, bad ventilation, and 
all the causes of cachexia. Specific infection (?) 

Diagnosis. — From vesicular eruptions, by the large size and isola- 
tion of the vesicles. From rupia, by the absence of thick scabs. From 
ecthyma, by the contents of the blebs being transparent. From erysi- 
pjelas, by the regular form and isolated situation of the blisters. 

Prognosis. — Generally favourable, but often chronic. 

Treatment. — That of the concomitant fever. In mild cases, 
gentle aperients, with quinine, and acid drinks. If the patient be 
cachectic alteratives with tonics or stimulants, and a generous diet. 

The local treatment consists in puncturing the vesicles as they 
appear ; and if there is much pain, the use of warm poultices or 
fomentations. 



( 629 ) 

RUPIA— ATOXIC ULCER. 

Synonym. — Ulcus atonicum. 

Symptoms. — This disease consists in round, flattened, and isolated 
blebs, about the size of a shilling, filled with serum, which changes 
after a time to pus. These blebs shrink, and become covered with 
thick brownish scabs, which, when they fall off, leave ulcers that either 
heal or continue open for a while. The disease attacks weakly and 
cachectic subjects, and runs a chronic course, lasting from a few weeks 
to several months. Its most common seat is the lower extremities. 

Varieties. — 1. Bupia simplex is the mildest form of the disease, 
and answers to the annexed description. — 2. Rupia prominens is named 
from the greater thickness of the scabs, which are formed by several 
layers of hardened secretion, assume a conical shape, and an appearance 
not unlike that of an oyster- shell in miniature. The blebs are larger, 
and the inflammation and subsequent ulceration more extensive than in 
rupia simplex. This form occurs chiefly in syphilitic subjects. — 3. 
Rupia escharotica affects infants in the interval from birth to the first 
dentition, is accompanied by much constitutional disturbance, and 
sometimes terminates fatally. The ulcers left after the separation of 
the scabs heal slowly, secrete a foetid sanies, and are apt to spread. 

Causes. — Predisposing, Syphilis, debility. — Exciting. Any de- 
rangement of the health. 

Diagnosis. — From pemphigus, by the thick laminated scab, the in- 
flammatory areola, and subsequent ulceration. From ecthyma, by the 
blebs at first containing serum ; but in severe cases, the secretions soon 
becoming purulent, renders the diagnosis difficult. 

Prognosis. — Favourable, except in severe cases of rupia escharotica. 

Treatment. — Local. Warm baths ; emollient applications, and 
when the ulcers are obstinate, nitrate of silver, dilute mineral acids, or 
stimulating ointments. — General. Tonics or stimulants, with altera- 
tives, according to the patient's state ; and strict attention to diet, 
ventilation, and cleanliness : — the treatment, in a word, of cachexia. 



C 630 ) 

Order IV. 
PUSTUUE— PUSTULES. 



Variola 
Vaccina 
Ecthyma 
Impetigo 
Acne . 
Equinia 



Small-pox (p. 307). 

Cow-pox (p. 313). 

Ecthyma. 

Running Tetter. 

Pimple. 

Glanders (p. 341). 



ECTHYMA. 



Symptoms. — The eruption begins as distinct, inflamed, circumscribed 
spots, which increase till they attain a considerable size. Pustules 
form on the centre, and sometimes enlarge till they closely resemble the 
bullae of rupia. In two or three days the pustules diy up, and thick 
scabs form, which, falling off, leave a purple discoloration, or in severe 
cases, and in greatly-impaired constitutions, an unhealthy ulcer. The 
eruption is sometimes accompanied by pain, and by slight fever. 

Causes. — Predisposing. Childhood and old age. — Exciting. All 
the causes of cachexia. 

Diagnosis. — From acne, impetigo, sycosis, famis, and scabies piru- 
lenta, by the larger size of the pustules, and their inflamed and in- 
durated base. From variola, by their size, the absence of the central 
depression, and their non-contagious character. From vaccina, by the 
cellular structure of the latter, and its contagious nature. 

Prognosis. — Favourable ; but sometimes chronic and tedious. 

Treatment. — Emollient applications, and if the ulcers assume a 
chronic form, nitrate of silver, or the dilute nitric or muriatic acid, or 
stimulating ointments. Gentle aperients and alteratives, mineral tonics, 
wholesome food, pure air, exercise, cleanliness, and sea bathing. 



IMPETIGO— CRUSTED TETTER. 
Synonyms. — Running tetter ; scale ; eowrap. 

Symptoms. — The eruption appears as clusters of small pustules, 
slightly raised above the skin, bursting in from one to three days, and 
discharging a purulent fluid, that hardens into thick, yellow, semi- 
transparent incrustations, resting on an irregular, inflamed base, moist- 
ened by a sero-purulent fluid. The eruption may disappear in a few 
weeks, or it may continue for months or years, the existing patches 
being succeeded by fresh groups of pustules. There is some constitu- 
tional disturbance, with heat and itching of the parts affected. 



ACNE. 631 

Varieties. — 1. Impetigo figurata generally occurs in defined patches 
on the cheeks, but may attack any part of the body ; is most common 
in spring, and in young children, especially during dentition. — 2. Im- 
petigo sparsa is more irregular in its distribution, and is most frequently 
seen on the extremities, and round the joints. It is most common in 
autumn ; and it may assume either an acute or chronic form. — 3. Im- 
petigo larvalis attacks the scalp, ears, and lips in infants. It may also 
occur on the cheek, which it covers with a thick, yellowish-white crust, 
resembling a mask, whence its name. In one of its forms it is known 
as crusta lactea. 

Causes. — Predisposing. The seasons of spring and autumn ; in- 
fancy and childhood ; the lymphatic temperament. — Exciting. The 
application of irritating substances to the skin ; unwholesome diet ; 
impure air ; want of cleanliness. The disease is not contagious. 

Diagnosis. — The pathognomonic character is the formation of clus- 
ters of small pustules (psydracia), succeeded by scabs of varying tints, 
from whitish-yellow to dark brown. The pustules of sycosis are much 
smaller, and the exsudation less. Favus is contagious, and the character 
of the crust distinct. (See Dermmycosis Favosa.) 

Prognosis. — Favourable, in the young and in its acute forms. Ob- 
stinate and difficult of cure in the old and in chronic forms. 

Treatment. — Emollient application, tepid baths, the vapour 
douche, and gentle aperients. The troublesome itching may be relieved 
by a prussic acid lotion, containing half an ounce of dilute prussic acid, 
and the same quantity of alcohol, in an eight-ounce lotion. In chronic 
impetigo, in addition to tepid baths, alkaline lotions to the skin ; the 
sulphur bath ; the dilute acids, or a weak solution of nitrate of silver. 
Unguentum kreasoti may also be usefully applied. 



ACNE— COPPER NOSE. 



Symptoms. — This disease attacks the sebaceous follicles of the skin, 
as isolated pustules, seated on a hard, red base, and terminating in 
indolent chronic tumours. Its primary form is, in most cases, a hard, 
red pimple. It is most commonly seen on the nose, cheeks, temples, 
and forehead, but frequently appears on the back and upper part of the 
chest, and sometimes on the neck and shoulders. It may exist in all 
these situations in the same person. It is a chronic disorder, not accom- 
panied by constitutional symptoms ; is most frequent from puberty to 
the age of thirty-five ; and occurs in both sexes. 

Varieties. — 1. Acne simplex answers to the foregoing description, 
its most common seat being the shoulders and upper part of the chest ; 
but it may occur on the face. — 2. Acne indurata consists in the forma- 
tion of large indurated tumours by the union of several of the smaller 



632 acxe. 

follicles. Its common seat is the face, but it often occupies the back of 
the trunk. — 3. Acne rosacea is generally met with in old persons, 
chiefly on the nose and cheeks. As the name implies, the diseased parts 
hare a rosy colour, which, however, is not permanent, but changes at 
length to a violet. In extreme cases, the superficial veins enlarge, and 
the cellular tissue, to some depth, becomes inflamed and hardened (acne 
indurata). — 4. Acne punctata derives its name from a small black spec, 
which occupies the summit of each pimple. — 5. Acne sebacea is 
named from the smooth waxy appearance which the eruption sometimes 
assumes. 

Diagnosis. — By its seat — the sebaceous follicles. 

Prognosis. — In acne simplex, favourable. It often disappears ot 
itself with the advance of age. Acne indurata and acne rosacea are 
often veiy obstinate, and defy all modes of treatment. 

Causes. — Hereditary predisposition ; dyspepsia ; excess in eating and 
drinking : uterine disorders ; change of life ; the application of irritating 
substances to the skin of the face. 

Treatment. — In young and vigorous subjects, when the disease is 
recent, a restricted diet, and the avoidance of all stimulating liquors ; 
gentle aperients ; spirit lotions, or lotions of the acetate of lead. In 
chronic cases, and in acne indurata, the same general treatment, varied 
according to the constitution and state of the patient. The local treat- 
ment will consist of frictions, with an ointment of iodide of sulphur 
fgr. xx of the iodide to an ounce of lard), or a paste of sulphur and 
milk. Dilute acids, or the nitrate of silver, cautiously applied to the 
eruption, or a lotion of two grains of the cyanide of mercury to an 
ounce of distilled water, are also beneficial. This lotion should be 
applied with a camel's-hair pencil, and, after a short interval, washed 
off with cold water. A course of alterative medicines may be given at 
the same time. A drop of kreasote in a mucilaginous draught may 
also be given with advantage two or three times a day. Acne rosacea 
requires a very careful regulation of the diet, proper exercise, abstinence 
from stimulating liquors, avoidance of heated apartments, hot fires, and 
mental excitement, with the local application of the vapour douche, or 
the lotion of cyanide of mercury. In very obstinate cases, blisters have 
sometimes been applied with advantage. 



( 633 ) 

Order V. 
PAPULAE— PIMPLES. 

LlCHEN. 

Prurigo. 
LICHEN. 

SYNONYMS. — Papulae sicca? ; scabies sicca vel agria. 

Symptoms. — An eruption of small, hard pimples, sometimes of the 
colour of the skin, sometimes red, generally arranged in patches or 
clusters, and accompanied by severe itching. Its most common situations 
are the hands, forearms, neck, and face, but it may attack other parts 
of the body. It is generally a chronic disorder, but sometimes assumes 
an acute form. Its usual termination is in desquamation. 

Varieties. — 1. Lichen simplex answers to the annexed description. 
— 2. Lichen strophulosus, commonly known as red gum, white gum, or 
tooth-rash, attacks children at the breast, or during dentition, is an acute 
affection, and generally continues for three or four weeks. It has re- 
ceived many names, according to the arrangement of the pimples, and 
the colour of the skin. — 3. Lichen urticatus is characterised by the large 
size of the papulae and their close resemblance to the sting of nettles. 
In lichen agrius, the papulae are confluent, and seated on a highly- 
inflamed base ; the pimples ulcerate and discharge a sero-purulent fluid, 
which dies into small scabs, and these, falling off, are replaced by thin 
scales. It is accompanied by intense smarting pain. — 4. Lichen syphili- 
ticus is characterised by the coppery hue of the rash. 

Causes. — Predisposing. The seasons of spring and summer. — Ex- 
citing. Extreme heat ; irritants ; abuse of ardent spirits ; jaundice ; 
disorders of the stomach and bowels ; and in children, the irritation of 
teething; syphilis. 

Diagnosis. — By the papular form of the eruption, the severe itching, 
and its non-contagious character. 

Prognosis. — Troublesome, and sometimes difficult of cure. 

Treatment. — In its acute forms, and especially in severe cases of 
lichen agrius, low diet, brisk aperients, and the antiphlogistic regimen, 
and tepid emollient applications. Chronic cases require stimulating 
applications ; such as a wash of carbonate of potash, ointments of iodide 
and biniodide of mercury, and sulphur and iodine vapour. 



( 631 ) 



PRURIG 0— PRURITUS. 

SYMPTOMS. — A chronic disease, in which the papulae are of the 
colour of the skin, larger than those of lichen, and accompanied by 
intolerable itching. It may occur on any part of the body, but is 
most common on the neck and shoulders. In some instances it attacks 
the external parts of generation in both sexes, or the margin of the anus. 
The papulae are apt to be torn by friction, and to present on their 
summit a minute clot of blood, which gives to the rash a very charac- 
teristic appearance. 

Varieties. — 1. Pmrigo mitts presents a smaller-sized pimple than, 
2. Prurigo formicans, and is attended with less itching. In the latter 
disease, the itching is greatly increased by the warmth of bed. — 3. Pru- 
rigo senilis is accompanied by great dryness of skin. 

Causes. — Predisposing. Childhood and old age, and the seasons of 
spring and summer. — Exciting. All causes of debility, and cachexia ; 
want of cleanliness ; unwholesome food, privation, friction, irritation of 
the skin or of the mucous membranes. 

Diagnosis. — From lichen, by the larger size of the pimples, by the 
dark spot on their surface, and by the more severe itching. 

PROGNOSIS. — Very difficult of cure, especially in aged persons. 

Treatment. — In prurigo mitis and formicans, tepid baths, and gentle 
aperients. In Pruritus senilis, hot baths, the sulphur bath, or the mixed 
vapours of iodine and sulphur. 



Order VI. 
SQUAMiE— SCALES. 



Lepra Vulgaris .... Scaly Leprosy. 

Psoriasis Dry Tetter. 

Pellagra Italian Leprosy. 

Pityriasis Dan drift. 

Ichthyosis Fish-skin. 

LEPRA VULGARIS— SCALY LEPROSY. 

Synonyms. — Kushta of the Hindoos; Baras of the Arabs. 
Lepra and psoriasis are considered separately for the sake of conve- 
nience; but there is no essential difference between them. 

Symptoms. — The eruption begins in the form of small, round, shining 
spots, slightly raised above the skin, and becoming soon covered with a 
thin white scale, which, falling off, leaves the surface of the skin red and 
scaly. The spot increases in size, still retaining its circular form, and 



' psoriasis. 635 

is raised at the circumference, and depressed towards the centre, and of 
a peculiar shining, silvery appearance. These patches vary in size, from 
a quarter of an inch to an inch and a half. The knees and elbows are 
the parts commonly affected, but the disease may appear on any part of 
the body. The spots are often arranged symmetrically on the upper 
and lower extremities. In cases of long standing, several of the original 
spots coalesce, and form large scaly patches of a very irregular shape, 
and the sensibility of the skin is destroyed. 

Varieties. — I. Lepra alpJioides is characterised by the small size 
of the patches, and the silvery appearance of the scales which cover 
them. — 2. Lepra nigricans is a rare disease, distinguished chiefly by 
its darker colour. 

Causes. — Predisposing. The season of autumn ; male sex ; adult 
age. — Exciting. Most probably syphilis. 

Diagnosis. — From syphilitic lepra, by the absence of the copper or 
violet colour, and the greater thickness of the scales. From favus, 
impetigo, and eczema, by the total absence of moisture, and by its scaly 
nature. The pustular and vesicular diseases produce scabs. From 
psoriasis, by the more regular shape of the patches. 

Prognosis. — The disease is essentially chronic, obstinate, and difficult 
of cure, and disappears and returns without obvious cause. 

Treatment. — This is chiefly local, consisting in the application of 
the tar ointment, or of the iodide of sulphur ointment, and of sulphur 
and salt-water baths ; and if the disease resist this treatment, prepara- 
tions of arsenic, or tincture of cantharides internally. The iodide of 
arsenic (the tenth of a grain three times a day). The constitutional 
treatment must depend on the existing state of health. 



PSORIASIS— DRY TETTER. 

Symptoms. — A chronic affection of the skin, consisting of irregular 
patches, often of considerable size, slightly raised above the surface, 
fissured, and covered with a white scale. There is some degree of 
itching, especially at night, but no marked constitutional disturbance. 
It attacks the eyelids, lips, prepuce, scrotum, backs and palms of the 
hands, and nails, and in some of these situations has received distinct 
names. Psoriasis palmavis (grocers' and bakers' itch) and Psoriasis 
dorsalis (affecting washerwomen) are common varieties. 

Varieties. — 1. Psoriasis guttata generally attacks adults in the 
form of small, round, red patches, often combined with the other forms. 
—2. Psoriasis diffusa is more irregular in shape and size. The patches 
are often of considerable extent, marked by large fissures, and commonly 
situated on the limbs. — 3. Psoriasis inveterata is a very severe form 
of the disease, and generally occurs in the aged and debilitated. The 



636 PITYRIASIS. 

skin becomes hard, thickened, and covered with a shining scale, which, 
when removed, leaves a red, fissured, painful, and bleeding surface. — 
4. Psoriasis gy rat a occurs in spiral-shaped stripes, generally on the back. 
It is very rare. 

Causes. — Predisposing. Hereditary predisposition ; adult age ; spring 
and autumn ; scrofula. — Exciting. Abuse of spirituous liquors ; un- 
wholesome food ; handling of dry powders. 

Diagnosis. — See that of Lepra. 

Prognosis. — An intractable disease, especially in old and weakly 
persons. 

Treatment. — After a short course of mild aperients, and strici 
regulation of diet, — alterative medicines, such as Plummer's pill, or th< 
fifth of a grain of the biniodide of mercury, with the external applica- 
tion of the iodide of sulphur ointment, or of the mixed vapour of iodine 
and sulphur. In bad cases of Psoriasis inveterata, preparations of arsenic, 
iodine, and mercury. (In Psoriasis inveterata attacking delicate anaemic 
females, Liquoris arsenicalis Tr\v, Tr. ferri perchloridi Tr\xx, Infus. 
quassiae 31', is a good combination. The itching and smarting are 
sometimes greatly relieved by a lotion consisting of ten grains of cyanide 
of potassium in six ounces of almond emulsion.) (G.) 






PELLAGRA— ITALIAN LEPROSY. 

Symptoms. — This disease is allied to psoriasis. It sets in in the 
spring of the year with dusky-red shining patches on the feet and back 
of the hands, which gradually spread, become studded with tubercles, 
and covered with dry scales, intersected, as in psoriasis, by cracks and 
excoriations. The rash is accompanied by slight itching. It subsides 
and disappears towards autumn to return the following spring in a 
more severe form, accompanied by anxiety, depression of spirits, and 
convulsive seizures. Towards the end of autumn the disease again sub- 
sides, but less completely, and reappears early the following year ; and 
now extends to eveiy part of the surface, the skin being dry, tough, and 
shrivelled like that of a mummy. Extreme debility, diarrhoea suc- 
ceeded by dysentery, dropsy, and epilepsy, follow each other, and w T ear 
the patient away, or usher in dementia or mania. 

Causes. — Obscure. Common in Lombardy and the north of Italy. 

Treatment. — The disease is believed to be incurable. The reme- 
dies prescribed for psoriasis should be persevered with. 



PITYRIASIS— DANDRIFF. 

Definition. — Non-contagious desquamation of the cuticle. 
Symptoms. — The disease consists in an abundant desquamation of 
branny scales, which are constantly renewed. Its common seat is the 



tubekcul^:. 637 

scalp, but it attacks other parts. There is itching of the skin, slight in 
some cases, severe in others ; but no constitutional disturbance. 

Pityriasis capitis occurs at all ages, and often in new-born infants ; 
is attended by slight itching ; and friction detaches numerous white 
branny scales. Pityriasis nigra is characterised by the black colour of 
the skin. 

Causes. — Predisposing. Youth and old age ; female sex ; debility. 
— Exciting. Irritation of the skin by heat, by the strong rays of the 
sun, or by chemical or mechanical irritants. 

Diagnosis. — Distinguished from the contagious diseases by the ab- 
sence of fungi. 

Prognosis. — Generally obstinate and difficult of cure. 

Treatment. — Cleanliness ; tepid baths ; and tonic and alterative 
medicines. Alkaline and lead lotions, the zinc or lead ointments, the 
ointment of nitrate of mercury, and sulphurous baths. The itching 
may be allayed by lotions containing prussic acid. 



ICHTHYOSIS— FISH SKIN. 



Symptoms. — The whole body, or certain parts only, especially the 
palms of the hands, soles of the feet, face, eyelids, outer surface of the 
limbs, and the joints, are covered by a number of small, hard, thick, 
dry, dark-brown rhomboidal scales, resembling somewhat the scales of 
a fish. The rash often has a very disagreeable odour, and is not ac- 
companied by inflammation, pain, or itching of the skin. 

Causes. — The disease is congenital. 

Treatment. — No treatment can be expected to remove the disease, 
but warm baths and the appropriate remedies may be used to keep the 
skin soft and comfortable. 



Order VII. 
TUBERCUL.E. 



Lepra Tuberculosa . . . Elephantiasis. 

Frambcesia The Yaws. 

Mollusc um Molluscum. 

Cheloidea Keloid. 

Malum Alepporum. 

LEPRA TUBERCULOSA— ELEPHANTIASIS. 

Synonyms. — Elephantiasis Graecorum. Lepra Egyptiaca. Lepr; 
Hebrseorum. 



638 FRAMBCESIA. 

Symptoms. — The disease commonly sets in with erythematous patches, 
upon which an eruption of soft, livid tumours, of variable size and ir- 
regular shape, makes its appearance. The skin and the subjacent tissues 
are hypertrophied and cedematous, and the parts affected ultimately 
attain an enormous size. The sensibility of the skin is heightened at 
first, but subsequently diminished. In very severe cases, the tubercle: 
become inflamed and ulcerated, and discharge an offensive sanies, which 
concretes into black scabs. The adjoining textures, even to the bone; 
sometimes become implicated, and their structure completely changed. 
The constitutional symptoms are merely such as result from the pro- 
longed sufferings of the patient. The disease may occur on any part, 
but is most common on the legs and face. 

Causes. — Predisposing. Hereditary taint ; syphilis ; the causes of 
scrofula ; certain climates. Dr. H. V. Carter * has adduced a number 
of cases which show that there frequently exists a close connection 
between a varicose state of the lymphatic system and elephantiasis. 

Prognosis. — Generally unfavourable. 

Treatment. — Stimulating applications externally, and arsenical pre- 
parations or cantharides internally, in combination with tonic infusions. 
Change of climate is sometimes beneficial. 



FRAMBQESIA— THE YAWS. 



Symptoms. — The disease sets in, without marked premonitory symp- 
toms, in the form of clusters, of variable size and shape, of small dark- 
red spots resembling flea-bites. On these spots papulae are developed, 
which degenerate into indolent vegetations, firm, slightly inflamed, 
covered with thin dry scales, and resembling, when found in circular 
groups, raspberries or mulberries. In some instances they become the 
seat of ulceration, and of a yellow or bloody discharge, which concretes 
into scabs. The surrounding skin is generally indurated. 

Causes. — Predisposing. The climate of the West Indies, and of 
parts of America and Africa ; scrofula. It is very rare among the white 
population. — Exciting. Contagion. 

Diagnosis. — By the peculiar appearance of the eruption. 

PPvOGNOSis. — Generally favourable. It sometimes assumes a chronic 
form, and continues for years. 

Treatment. — The local application of stimulants, such as the red 
oxide, or yellow iodide of mercury ; caustic, or the actual cautery. In- 
ternally, tonics and alteratives, and mercurial preparations in small 
doses ; and in chronic cases, the preparations of arsenic. Warm, and 
vapour baths. 

* Trans. Med. and Phys. Soc. Bombay, No. vii. 1861, p. 186. 



( 639 ) 



MOLLUSCUM. 

Symptoms. — Numerous indolent tubercles, from the size of a pea to 
that of a pigeon's egg, of various forms, sessile or pedunculated, of the 
natural colour of the skin, containing a little sebaceous matter, unac- 
companied by any constitutional disorder, and not attended by pain, in- 
flammation, or ulceration. They present a central depression, leading 
to an orifice, which is closed with a plug of discoloured sebaceous or 
albuminous matter. After the removal of this, a coarse needle may be 
passed down the tumour to some distance within the skin. 

Pathology. — Morbid alteration of the hair follicles. The sebaceous 
glands are sometimes atrophied. 

Causes. — Obscure. One form of the disease is contagious. 

Treatment. — Fowler's solution was administered by Bateman with 
success. Biett recommends a solution of sulphate of copper. 



CHELOIDEA, 

Synonyms. — Cancroide ; keloide. 

Symptoms. — This is a rare disease, appearing as hard, indolent tu- 
bercles, varying in dimension from a very few lines to a few inches, 
generally isolated, but sometimes in groups, with intervals of sound 
skin. They are of an irregular oval, square, or angular shape, of a 
rose or red colour, with a depressed centre, and covered with a thin 
layer of wrinkled cuticle. They have a remote resemblance to a crab 
or tortoise — whence the name. The usual situation of these tumours 
is the space between the mammae. They are generally chronic, and 
unattended with danger. 

Diagnosis. — By the peculiar appearance above described. 

Treatment. — The local application of the vapours of sulphur, 
iodine, or mercury ; of plasters containing iodine, or iodine and opium ; 
and alkaline baths. 

The disease advances slowly, and is unattended with danger. The 
tumours rarely ulcerate ; they are generally chronic, but occasionally 
they disappear spontaneously, leaving a white cicatrix-like mark. 



MALUM ALEPPORUM. 



Definition. — A tubercular disease of the skin which prevails en- 
demically at Bagdad, in several towns on the banks of the Tigris and 
Euphrates, and particularly at Aleppo. 



640 lupus. 

Symptoms. — The eruption of one or more tubercles varying in size. 
At first the tubercle is merely a lenticular eminence, which during the 
next four or five months gradually increases without local or general 
symptoms. Acute pain now sets in, followed by deep-fissured and 
irregular ulceration, discharging a thick, ill-conditioned matter. After 
five or six months, a dry tenacious scab is formed, which dessicates and 
separates in the course of one or two months, leaving a deep indelible 
scar. It attacks persons of all ages, sexes, and conditions of life. Dogs 
are also liable to it. Children are attacked about the age of two or 
three ; and at Aleppo, according to M. Guilhon, scarcely a single adult 
escapes. 

Cause. — Attributed at Aleppo to the use of water from a particular 
stream. A healthy constitution affords no protection. The disease is 
rarely complicated with scrofula ; is not contagious ; nor is it dan- 
gerous. There is no specific plan of treatment known. 



Order VIII. 
MAC UL£— SPOTS. 



The diseases belonging to this order are of little practical importance. 
They consist either in change of colour (color ationes) or loss of colou 
{decolor -ationes). To the former belong the common freckle {lentigo 
and ephelis), the mole (spUus), purpura, petechia?, bruises, the severa" 
forms of ncEvus ; to the latter, the universal colourless state of the 
skin {albinismus), and the partial absence of colour {vitiligo). 



OTHER DISEASES OF THE SKIX. 
LUPUS— THE WOLF. 

Synoxyms. — Lupus vorax ; Herpes exedens ; Formica corrosiva. 

Symptoms. — This disease, in all its forms, is characterised by its 
tendency towards destructive ulceration of the pails which it attacks. 
It commonly attacks the face, beginning in an ala of the nose. It is 
rare on the trunk or extremities. 

Varieties. — 1. The superficial form of lupus is sometimes confined 
to the skin, from which the cuticle exfoliates, and leaves the true skin 
red, shining, and tender to the touch, and bearing a close resemblance 
to the recent scar of a superficial burn. The redness disappears on 
pressure. When the disease is arrested it leaves the skin thin and 
shining, and as if seared by a hot iron. 

2. The deep-seated form of the disease generally attacks the alae of 
the nose, and is often preceded by redness, swelling, pain, and mucous 



FARUNCULTJS. 61-1 

discharge from the nostrils. The skin first swells and assumes a violet - 
red colour. After an interval, a small ulcer forms, covered by a scab, 
beneath which a gradual destruction takes place, first of the skin, then 
of the cartilages. In extreme cases, the whole nose and even the palate 
and gums are destroyed ; but in some instances, the disease lasts for 
years without occasioning any great amount of destruction. 

3. The tubercular form consists in numerous small, soft, red tuber- 
cles, which remain stationary for a few weeks, months, or years, and 
then suddenly become inflamed and enlarged ; their bases unite, and 
their summits ulcerate, forming an irregular spreading ulcer, covered 
by a dark tough crust. The parts first attacked sometimes partially 
heal, leaving irregular scars, which become the seat of fresh tubercles 
and renewed ulceration. The usual seat of this form is the cheek, but 
it may occur on the neck and chest, and on the anterior surface of the 
extremities. 

4. Lupus with hypertrophy is generally confined to the face, and 
consists in the formation of numerous soft, indolent tumours, which 
rarely ulcerate, but enlarge at their bases, and the skin and cellular 
tissue become hypertrophied. The entire face, in this manner, some- 
times attains an enormous size, and is hideously disfigured. 

These forms may exist together, leading to the destruction of the 
nose, eyelids, and lips, and producing frightful deformity. They are 
rarely accompanied by any marked constitutional symptoms. 

Causes. — Predisposing. The periods of childhood and youth ; less 
frequently the adult age up to 40 ; the female sex ; the scrofulous 
diathesis. — Exciting. Obscure. It is not contagious. 

Diagnosis. — From acne, by the absence of pustules. From tuber- 
cular lepra, by the insensibility of the skin, and the peculiar fawn 
colour of the tubercles in this latter disease. From epithelioma, by 
the latter beginning in a single point, surrounded by a hard, circum- 
scribed base, and accompanied by severe darting pains. 

Prognosis. — Favourable, when recent and limited, — Unfavourable. 
when of long continuance and extensive. 

Treatment. — This must be chiefly local, and will consist, where 
the ulceration has not set in., of friction with stimulating ointments 
containing the iodides of sulphur and mercury. When ulceration has 
set in, styptics must be used, such as nitrate of silver, chloride of anti- 
mony, and the nitrates or iodides of mercury. Alteratives such as iodide 
of potassium and mercury should be given for a considerable time, and 
resumed after short intervals. 



FARUXCULUS— BOIL. 

Symptoms. — Boils consist of hard, circumscribed, dark-red tumours 
of the cellular membrane, attended by troublesome itching and smart- 
ing, sometimes terminating in lesolution, but more frequently passing 

2 T 



642 FARUXCULUS. 

into suppuration and the slow discharge of matter by a single orifice, 
or by several small openings. Several of these boils follow each other 
in quick succession, and may continue to harass the patient for weeks 
together. They are most common on the neck, back, and nates. They 
are attended with slight constitutional disturbance. 

Carbuncles are boils of larger size and more marked character, and 
are attended by extensive sloughing of the cellular membrane. 

Causes. — Predisposing. Debility, cachexia, and old age. — Exciting. 
Obscure. The mortality from carbuncles in the metropolis rose from 
1, 2, 3, or 4 per million, per annum, from 1840 to 1846, to from 7 
to 36 per million, per annum, in the interval from 1847 to 1854. 

Diagnosis. — From phlegmon, by the subacute character of the in- 
flammation, and limited seat of the disease. 

Prognosis. — Boils are often tedious, but rarely fatal ; but car- 
buncle, especially in aged persons, is often attended with great danger. 

Treatment. — In mild cases, saline aperients to keep up a free 
action of the bowels, and poultices to the boils, when inflamed and 
painful. In more severe cases, the boils to be freely incised and then 
poulticed. In carbuncle, free crucial incisions, followed by poultices, 
and a generous diet, with wine and stimulants. In lingering cases, a 
course of alterative tonics 'see Form. 5, 15, and 31 y . In most cases 
of carbuncle we may give bark and ammonia at the outset. Subse- 
quently quinine and acids are required. 



The affections of the skin which characterise secondary syphilis have 
been briefly described under Syphilis, page 579. 



( 643 ) 



CHAPTEE IX. 

PARASITIC ANIMALS. 

1. Intestinal Worms. 

2. Other Parasitic Animals. 

INTESTINAL WORMS. 

1. Ascaris Lumbricoides . . . . Round Worm. 

2. Ascaris Vermicularis .... Thread-worm. 

3. Trichocephalus Dispar .... Long Thread-worm. 

4. Trichina Spiralis. 

5. Taenia Tape-worm. 

6. Bothriocephalus Latus .... Broad Tape-worm. 

ASCARIS LUMBRICOIDES— ROUND WORM. 

Synonym . — Lumbricus . 

Symptoms. — These vary with the number of the worms and the part 
of the alimentary canal which they occupy ; sometimes (though rarely) 
there is only one worm. The symptoms commonly present are an un- 
easy sensatiou in the abdomen, sometimes amounting to actual pain, and 
often described as a biting or gnawing ; hardness and swelling of the 
belly ; an irregular state of bowels, with scanty evacuations of mucus, 
sometimes tinged with blood ; tenesmus, and, in some cases, dysuria ; a 
variable and sometimes excessive appetite ; foetid breath, and furred 
tongue. There is itching at the nose and anus, and picking of these 
parts, and grinding of the teeth in sleep. The constitutional symptoms 
often amount to those of infantile remittent fever (see p. 332) in young 
children, and convulsions are sometimes traceable to this cause. It has 
also given rise to chorea, headache, giddiness ; to dry cough and spasmodic 
asthma ; to violent palpitations, and severe hysterical symptoms. In 
most instances the general health does not suffer in any appreciable 
degree. 

Diagnosis. — There is no certain sign of the presence of these worms 
till they are discovered in the motions, either with or without the opera- 
tion of medicines. In some cases they have been discharged from the 
stomach. They occasionally find their way into the gall bladder and 
bile ducts, and may give rise to abscess of the liver. Their common 
habitat is the small intestines. They vary from half a foot to a foot in 
length. The annexed woodcut shows a specimen of this worm of moderate 



644 



ASCARIS LUMBRICOIDES. 



Fig. 93. 



size; the head, b, is magnified about fourfold. It is terminated by three 
papillse, which can be spread out into a broad circular sucker during 
the act of sucking. 

The posterior extremity of the female 
(Fig. 93) is comparatively slender and 
pointed. The corresponding part of the 
male is bent round like a hook. 

The fecundity of this entozoon is pro- 
digious. Dr. Eschricht calculates that the 
body of the mature female contains at a 
given time as many as 64 millions of 
eggs. 

Prognosis. — These worms when once 
proved to exist may generally be re- 
moved by appropriate remedies. 




- Predisposing. Childhood 
A cachectic state of consti- 



Causes. 
and youth, 
tution. 

Exciting. — It is probable that the ova 
are introduced into the alimentary canal 
with unripe fruit and vegetables, or with 
impure water. 

Treatment. — The parasite is readily 
expelled by irritant purgatives. Of these 
the Pulvis scammonii compositus is the best. 
It may be given alone or in combination 
with a few grains of calomel. Santonica, 
or, better, its crystaliizable santonine, is a 
specific against this entozoon. Santonine 
is not itself purgative, and therefore it 
may be given to the most delicate children. 
The dose varies from gr. i to gr. vi. It 
may be given at bedtime, and generally 
should be followed by a purge such as 
gr. x to gr. xv of Pulvis scammonii com- 
positus, or the purgative may con- 
veniently be combined with the anthel- 
mintic. If the use of these remedies by 
mouth be contra-indicated, enemata of strong infusions of worm- 
wood, rue, tansy, or santonica may be given. 

Cowhage (the hairs of the pod of Dolichos pruriens) is a good re- 
medy. It should be made into a smooth electuary with treacle, and 
given in doses of one or two teaspoonfuls for two or three nights in 
succession, its use being preceded and followed by an aperient. 



( 645 ) 



ASCARIS VERMICULARIS— THREAD-WORM. 

Synonyms. — Oxyuris vermicularis. As- Fig. 94. Fig. 95. 

carides. Maw-worm. 

Symptoms. — This worm chiefly infests 
the large intestines and especially the rectum 
in considerable numbers, and gives rise to 
great irritation at the verge of the anus. 
In consequence of their small size they are 
not only contained in the evacuations, but 
crawl out of the rectum, so as to be found 
in the clothes or in the bed, and in females 
they find their way into the vagina, and cause 
irritation there. In adult males, they are 
among the causes of spermatorrhoea. The 
constitutional symptoms are those de- 
scribed above. (See Ascaris lumbricoides.) 

Diagnosis. — The only certain proof of 
the existence of these worms is their pre- 
sence in the evacuations, or on the person 
of the patient. Fig. 94 represents the 
female eight times the natural size. Fig. 
95 still more highly magnified; d, 
stomach ; e, oesophagus ; g, anus ; h, ova- 
ries; k, oviduct. They are often found 
massed together into large round balls. 
The male is disproportionately small ; both 
extremities are rounded and obtuse, and it has a pale 
silver-grey colour. The females, which are much 
more numerous, are distinguished by their thickness 
and whiteness and by the fine pointed tail. 

Mode of Introduction. — Nothing is certainly 
:known respecting the habitat of the parasite out of the 
body. It is supposed to be conveyed into the intes- 
tines in the embryonic condition, by means of salads 
and unripe fruits. 

Prognosis. — These worms are easily removed by 
remedies ; but from their large numbers and rapid pro- 
duction, it is not easy to insure their complete expul- 
sion. New broods are also frequently developed. 

Treatment. — Injections are the most appropriate Xio 
remedies. Jiv to Jvi Liquoris calcis, or the same 
quantity of Infusum anthemidis or Infusum quassia?, 
:hrown into the rectum, are efficacious remedies. The 
worms are, however, discharged in considerable num- 
>ers by the. use of aperients. (Form. 284, 285.) 



'M 



( 646 ) 



TRICHOCEPHALUS DISPAR. 



SYNOHYMS. — Trichuris, or Long Tread-worm, is a species com- 
monly found in the caecum and colon. It is distinguished from the 
common thread- worm by its greater length, the extreme tenuity of 
the anterior two-thirds, and the increased size of the posterior third 
of the body. Also, in the case of the male, by the peculiar form of 



Fig. 96. Fig. 97. 



the spiculum and sheath, shown greatly magnified at b (Fig. 96). 
The posterior part of the body is commonly found coiled up as in 
Fig. 97, which shows the worm of its natural size. These little 
worms vary from an inch and a half to two inches in length. The 
males are shorter and more slender than the females. The eggs are 
oval. The parasite has been observed in Egypt, Ethiopia, France, and 
in England. In this country it is considered to be rare, but in France 
it is very common. According to M. Davaine, not less than one-half the 
inhabitants of Paris are affected by this entozoon. 

The treatment is that of the common thread-worm ; but injections 
are less necessary. 



TRICHINA SPIRALIS— TRICHIXATOUS DISEASE. 

Attention has been directed of late to a train of symptoms associated 
with the development of this parasite in the system, and stated to be 
directly due to its presence. 

Symptoms. — Extreme lassitude and depression ; sleeplessness and 
loss of appetite ; pyrexia, accompanied by severe muscular pains, and 
occasionally oedema of the joints, followed sometimes by painful and 
persistent contractions of the flexor muscles of the extremities. In 
many cases the disease sets in with diarrhoea, and it usually terminates 
in pneumonia. In some cases typhous symptoms come on and the 
patient dies unconscious. The disease, when fatal, runs its course 
within a month of the introduction of the parasite. 

Mobbid Anatomy. — Muscles, pale reddish grey, speckled with 
minute lighter-coloured points, which, on minute examination, prove to 
be Trichina in all stages of development, lying free upon and within 
the sheaths of the muscular fibres. They pervade all the voluntary 
muscles, and have been observed in the substance of the heart. 



TKICHINA SPIKALIS. 



647 



Source of the Parasite. — Pigs in Germany are infested with 
Trichinae, and their propagation within the human body is secured by 
the ingestion of raw or imperfectly cooked pork or sausages. The 
domestic animals are readily infected by the same means. Dr. W. 
Miiller, of Homberg, states ("Lancet," Jan. 23, 1864, p. 93), that 
an epidemic of trichiasis occurred in Hettstaedt, in Prussia, from eating 
imperfectly cooked sausages made of pork infected with the parasite. 
At one time eighty out of a population of about 5500 were afflicted 
with the disease, and eighteen or twenty had previously died of it. 

Man is infested with this parasite much more frequently than was 



Fig. 



Fig. 99. 





at first supposed ; for Dr. Zenker, of Dresden, found Trichinae in four 
out of 136 dissections. 

The Trichinae begin to develop almost immediately after their intro- 
duction into the stomach, males, females, and innumerable embryos 
being produced within the intestinal canal, whence, by means that have 
not been ascertained, the latter make their way to their favourite 
habitat, the muscles, and produce the violent symptoms above men- 
tioned, until they become enclosed within capsules, in which state they 
are harmless. Fig. 98 represents the animal incapsulated amongst the 
muscular fibres ; Fig. 99 the free mature animal. 

The non-encysted animals are not visible to the naked eye. The 



648 T^XIA 

encysted also, unless they have undergone cretaceous degeneration, 
require the aid of a pocket lens for their detection. 

Treatment. — Since the parasite is carried into the most distant 
parts of the hody with astonishing rapidity, "no remedy can be of any 
avail unless it obtain, like santonine, a speedy admission into the blood. 



T.EXIA— TAPE-WORM. 




Fig. 101. 



Svmptoms. — Those already 
described under Ascaris lumbri- 
coides. The tape-worm occupies 
the whole track of the intes- 
tines, but chiefly the ileum. 
Joints of the worm (B, Fig. 100) 
frequently pass from the bowels, 
even without medicine, or they 
escape as the patient moves 
about. 

Diagnosis. — The appearance 
of the joints, or proglottides, 
in the motions. They are flat, 
about an inch long, and a quarter 
of an inch broad, and present a 
little, round, cup-shaped aper- 
ture upon one or other side. 
Two species are met with, the T. 
solium, and the T. mediocanel- 
lata. In hospital practice in 
London 1 find the latter by far 
the most common. At first sight 
there is very little to distinguish 
these two species of parasites. 
They vary in length from four 
to twenty feet. T. mediocanel- 
lata is the larger and more robust 
form ; it is known by the ab- 
sence of rostellum and hooklets, 
and by the more ramified form 
of the uterine organ. These two 
forms are illustrated in Figs. 1 00, 
101. A represents the anterior 
extremity of T. mediocanellata, 
natural size. B, X6 showing the 
flat head, the sucking discs, and 

the absence of hooklets. C one of the joints x about 2. 

D, X 4 and E, X 2 show the corresponding parts of T. solium. The 

ripe joint, or proglottis, is the adult hermaphrodite animal, capable of 




l^Mj 



BOTHRIOCEPHALIC LATUS BEOAD TAPE-WORM". 



649 



maintaining an independent existence. The branched organ in the centre 
is the uterus or ovisac, and contains thousands of ripe spherical eggs. 

Prognosis. — It is easy to remove considerable portions of the worm 
by various remedies. The entire worm is less frequently expelled. 
Search should always be made for the head. Until this is expelled, the 
patient is not effectually relieved ; but when any number of the small 
joints at the upper end of the worm are expelled, there is a probability 
in favour of the head having also been removed. 

Source of the Parasite. — Taenia solium is derived from pork, 
which is liable to be infected with its larval form known as Cysticercus 
cellulosce. Taenia mediocanellata is in like manner admitted into the 
body by means of veal and beef, which often contain the larval form of 
this species. 

Prophylaxis, — In order to prevent the development of the parasite 
all animal diet should be perfectly cooked, so that the meat, when 
brought to table, should be firm, and destitute of tremulousness and 
blood colour. Pork and sheep's brains, in particular, should be com- 
pletely cooked. The pernicious habit of eating imperfectly cooked meat 
doubtless results in other diseases besides those due to parasites. 

Treatment. — Oil of turpentine, in the dose of half an ounce, 
followed in two hours by an ounce of castor-oil. This treatment rarely 
fails of removing the tape- worm, but it is open to the objection that 
the turpentine acts as a stimulant to the brain and urinary organs, 
sometimes producing painful strangury. It is much less apt, however, 
to produce this effect if speedily fol- 
lowed by castor- oil. Kosso, in the 
form of infusion (^ss — Ji to Oss of 
water), taken at a single dose. This 
is an extremely effective remedy. The 
liquid extract of the male fern -root in 
the dose of 5i or 3 iii. It may be 
given in capsules. This remedy never 
fails to expel the parasite. 

The Kamela or Rottlera tinctoria 
in the dose of gr. 1 to gr. c in water. 

These remedies should be given on 
an empty stomach : an ounce of castor- 
oil should be taken over night, the 
anthelmintic in the morning, and a 
second ounce of castor-oil two hours 
afterwards. No food to be taken while 
the medicines are being administered. 



Fig. 102. 




BOTHRIOCEPHALUS LATUS— 
BROAD TAPE-WORM. 

Symptoms. — Those of Taenia. The Bothriocephalus latus is very 
rare in England. It is as common in Switzerland and Russia as 



650 ANIMALS PARASITIC WITHIN MAN. 

Taenia is in England. It occurs in France, in common with the Taenia 
solium. 

Diagnosis. — From the common tape -worms by the shape of the 
head, which is marked in the direction of its length by a groove, and 
by the absence of rostellum, hooklets, and suckers. The proglottis is 
also quite distinct. The head, a and b, and some of the mature seg- 
ments, c and D, are shown in the subjoined engraving ; B and D are 
magnified. (Leuckart.) 

Treatment. — That of the common tape-worm. 



OTHER ANIMALS PARASITIC WITHIN MAN. 

In addition to the animal parasites particularly treated of in the pre- 
ceding pages and body of the work generally, the following are occa- 
sionally met with : 

Cestoidea. — Taenia cucurbitina, grandis, saginata, acanthotrias. 
flavopuncta, marginata, nana, and elliptica (T. canina). Bothryo- 
cephalus cordatus. These parasites inhabit the alimentary canal, but 
may be carried to any part of the system. 

Tbematoda. — Distomum hepaticum. crassum, lanceolaturn, hetero- 
phyes. These parasites inhabit the portal vein and gall ducts. Dis- 
tomum ophthalmobium has been found in the eye. (?) 

Nematoidea. — Ascaris mystax (intestines) ; Filaria oculi seu lentis ; 
Filaria bronchialis ; Tetrastomum renale and Strongylus gigas (in the 
kidney) : Anchylostomum duodenal e (duodenum , ; Spiroptera hominis 
and Dactylius aculeatus (discharged from the bladder J. 

The treatment of these parasitic animals will be determined by their 
locality and the symptoms which they occasion. The tape-worms 
require the same remedies as T. solium. The Ascaris mystax and 
Anchylostomum duodenale, may be expected to yield to the treatment 
prescribed under Ascaris lumbricoides. When the parasites are known 
to inhabit the bladder, the injection of bitter infusions may be em- 
ployed. 



( 651 ) 

CHAPTEE X. 

POISOXS. 

The subject of Poisons is here treated simply as a branch of the 
Practice of Medicine. For minute details of their tests, symptoms, 
post-mortem appearances, antidotes, and proper treatment, the reader is 
referred to works on Toxicology, or Forensic Medicine. The antidotes 
for the principal poisons are given at the end of the chapter. The old 
division is retained, as being convenient in practice, into : 1 . Irritant 
Poisons. 2. Narcotic Poisons. 3. Xarcotico-irritant Poisons. 



1. IRRITANT POISOXS. 



Definition. — Poisons which cause corrosion, inflammation, or irrita- 
tion in the alimentary canal, with or without specific remote effects on 
other organs. 

Symptoms. — After an interval varying from a few seconds to half 
an hour or more from the swallowing of the poison, vomiting and 
purging, with pain in the stomach and bowels, increased by pressure ; 
and accompanied by inflammatory fever, or extreme prostration of 
strength. Pain and constriction of the mouth, throat, and gullet, ac- 
companying or following the act of swallowing ; intense thirst ; hoarse 
voice, wheezing respiration, and cough ; discharge of blood from the 
stomach and bowels; tenesmus; strangury, dysuria, or suppression of 
urine ; convulsions and epileptic seizures ; and cutaneous eruptions, are 
symptoms of more or less frequent occurrence, but not present in every 
instance. The remote constitutional effects, whether common to other 
severe injuries, or specific, are also subject to great variety. 

Morbid Appearances. — Marks of corrosion, inflammation, sup- 
puration, or gangrene in the stomach and upper part of the alimentary 
canal, extending, in certain cases, to the gullet, throat, and mouth, and 
through the whole length of the intestines. Perforation of one or other 
of these parts. In certain cases, signs of inflammation in the windpipe 
and lungs ; in the peritoneum and pleura ; in the rectum and bladder ; 
in certain other cases, peculiar stains or indications of the action of the 
poison on the mouth, throat, gullet, stomach, and duodenum. 

Diagnosis. — During life, from English and Asiatic cholera, in many 
cases of irritant poisoning, by the blood mixed with the evacuations 
from the stomach and bowels, and in many other cases by the effect of 
the poison upon the mouth, throat, and gullet. In other instances, 
again, by the specific remote effects of the poison. (E.g. inflamed 
eyes, gastritis, and rapid pulse, in poisoning by arsenic ; salivation in 



652 NARCOTIC POISONS. 

poisoning by the preparations of mercury : jaundice, in poisoning by 
phosphorus and the preparations of copper ; pneumonia, and extreme 
depression, in poisoning by tartar emetic ; inflammation of the urinary 
organs, in poisoning by cantharides and phosphorus.) After death, by 
the traces of acute inflammation, and its consequences in the several 
portions of the alimentary canal ; and in many cases by appearances in 
the upper part of the canal appropriate to particular irritant poisons, or 
to the corrosive poisons as a sub-class of the irritants. 

Prognosis. — Dependent on the nature of the poison, the degree of 
concentration, the vehicle, the dose, the prompt administration or other- 
wise of an antidote, the state of the stomach (whether full or empty) 
when the poison was swallowed, and the age and strength of the 
patient. 

Mortality. — The mortality varies, in the case of the several poisons 
contained in this class, from more than half the cases down to a rarely 
fatal result. 

Treatment. — After the administration of an antidote if any exist), 
the prompt and complete evacuation of the stomach by the stomach- 
pump (except in the case of strong corrosive poisons), or by emetics of 
common salt, mustard, ipecacuanha, or sulphate of zinc, assisted by 
large draughts of warm water, and tickling the throat with a feather 
or with the finger. After the evacuation of the stomach, the free use 
of milk, gruel, barley-water, and abstinence from all solid food. When 
inflammation runs high, ice or iced-water : when great tenderness is 
present, leeches followed by warm fomentations. When the bowels 
cease to discharge blood, and the patient suffers from tenesmus or con- 
stipation, one or two tablespoonfuls of castor-oil, with twenty drops or 
half a drachm of laudanum, mixed with a small quantity of hot milk. 
Extreme prostration will require the use of larger doses of laudanum, 
with wine or brandy. When fever runs high, it may be necessary to 
draw blood from the arm. Occasional symptoms, and symptoms peculiar 
to certain poisons only, must be treated in the same manner as the same 
symptoms due to other causes. 



2. NARCOTIC POISONS. 



Definition. — Poisons w T hich act on the brain and spinal marrow, 
and five rise to symptoms referable to those organs, without exciting 
any irritation or inflammation of the alimentary canal. 

Symptoms.— After an interval, varying from a few seconds to one 
or two hours from the swallowing of the poison, the patient is seized 
with giddiness, headache, dimness of vision, singing in the ears, drowsi- 
ness passing into stupor, and ending in complete coma, with palsy, 
convulsions, epileptic fits, or tetanic spasms. 



XARCOTICO-IRRITAXT POISONS. 653 

Morbid Appearances. — Often very slight. The brain sometimes 
healthy ; the veins and sinuses sometimes gorged with blood : with 
serum in the ventricles and at the base. In rare instances extravasation 
of blood. 

Diagnosis. — From the close resemblance of the symptoms of some 
forms of narcotic poisoning and of apoplexy, no satisfactory diagnostic 
marks can be laid down for narcotic poisons as a class ; and in any case 
the history of the first appearance and progress of the symptoms will 
constitute our principal means of distinction. 

Prognosis. — This, too. cannot be laid down for the entire class, as 
the chances of recovery vary very greatly with the particular poison 
which has been taken. 

Treatment. — The prompt use of the stomach-pump, and, until 
that can be procured, the administration of emetics of common salt, 
mustard, ipecacuanha, or sulphate of zinc. The cold affusion as a 
shock, especially in the early stage of the poisoning. The patient to 
be kept awake by walking him up and down, or by flecking his hands 
and feet with a wet towel. After the complete evacuation of the 
stomach, strong coffee and tea, and diffusible stimulants, to be freely 
administered. The bowels to be relieved by full doses of castor-oil. 
So long as the surface continues cold and livid, the heat to be restored 
by assiduous frictions, and by warm bottles to the feet and pit of the 
stomach, or by the hot-air bath. In extreme cases, artificial respiration, 
and galvanic shocks passed from the spine of the neck to the pit of the 
stomach. This is the treatment of cases of poisoning by opium. In 
poisoning by prussic acid, the cold affusion is the first remedy to be 
employed ; and in cases which survive some minutes or hours, heat and 
assiduous frictions, to restore warmth to the surface, must take the 
place of the compulsory exercise necessary in poisoning by opium, and 
by other poisons producing well-marked narcotic effects. 

For the treatment of poisoning by chloroform, see page 426. 



3. NARCOTICO-IRRITANT POISONS. 
Synonym. — Xarcotico-acrids. 

Definition. — Poisons which produce the combined effects of the 
irritant and narcotic poisons ; the irritant action being generally less 
violent than in the case of the pure irritants, and delirium being 
of more common occurrence than in cases of poisoning by the pure 
narcotics. 

Symptoms. — At an interval varying from about an hour to three 
or four hours after swallowing the poison (which, in many cases, has a 
peculiar taste), giddiness, disorders of the senses of sight and hearing, 
delirium, convulsions, tetanic spasms, stupor passing into coma ; pre- 



654 poisons. 

ceded or accompanied by vomiting and purging, with pain and tender- 
ness of the abdomen. As a general rule the narcotico-irritants act 
chiefly or wholly as narcotics in very large doses, and mainly as irritants 
in small doses. 

Morbid Appearances. — Xot strongly marked or uniform, con- 
sisting of marks of inflammation in the stomach and intestines, with 
congestion of the brain. 

Diagnosis. — From most of the pure irritants by the presence of 
symptoms of narcotic poisoning. From the pure narcotics by the pre- 
sence of more or less irritation in the alimentary canal. 

The following indications of particular poisons or groups of poisons 
may be added : — 

Delirium affords a presumption of poisoning by belladonna, hyoscy- 
amus, and stramonium, or some plant belonging to the natural order, 
Solanacece. Symptoms of intoxication give a like presumption of the use 
of alcohol, aether, chloroform, or of some liquid or gaseous hydro-carbon ; 
Tetanic convulsions are nearly conclusive of the presence of strychnia, 
or of some substance containing it ; extreme muscular weakness affords 
a presumption of the operation of hemlock, aconite, tobacco, lobelia 
inflate, and the Calabar bean; sudden prostration following quickly on 
the swallowing of the poison afford a strong presumption of the action 
of prussic acid, or oxalic acid ; and a very slow and weak pulse attends 
poisoning by digitalis. 

Prognosis. — Dependent chiefly on the early or late commencement 
of the treatment, and on the circumstances mentioned under Xarcotics. 

Treatment. — The prompt use of the stomach-pump, or of emetics, 
followed by aperients and enemata, if required. The rest of the treat- 
ment to be determined by the symptoms piesent; if chiefly those of 
irritant poisoning, the treatment proper to that class of poisons ; if 
chiefly of narcotic poisoning, the treatment prescribed under Narcotic 
Poisons. 



( 655 ) 



AXTIDOTES TO THE PRINCIPAL POISOXS. 

Acids, Mineral. — Calcined magnesia or carbonate of magnesia ; 
common chalk, whiting, prepared chalk, or compound chalk 
powder ; a dilute solution of carbonate of soda, or potash ; in an 
emergency, the plaster of an apartment, broken up and diffused 
through water; soap suds, or oil. 

Acids, Vegetable. — Magnesia, common chalk, whiting, prepared 
chalk, or compound chalk powder. Carbonate of soda. 

Alum. — Calcined magnesia. 

Ammonia and its Carbonate. — Vinegar and water, oil. 

AntimonYj Chloride of. — Magnesia, carbonate of soda. Tincture of 
bark. 

Arsenious Acid and the Soluble Arsenites. — No certain anti- 
dotes. Hydrated oxide of magnesia ; magnesia in a state of fine 
division ; the hydrated sesquioxide of iron ; or powdered charcoal 
may be given. Also, a mixture of oil and lime water. 

Baryta, Soluble Salts of. — Sulphate of magnesia or of soda. 

Baryta, Carbonate of. — Sulphate of magnesia with weak vinegar. 

Chlorine. — Ammonia ; magnesia. 

Hydrocyanic Acid. — After cold affusion, liquor chlorinii, the mixed 
oxides of iron diffused through water, ammonia, and the treat- 
ment of asphyxia : 

Iodine. — Starch ; a very dilute solution of caustic potash or soda. 

Iron, Sulfhate of. — Carbonate of soda or carbonate of ammonia. 

Lead, Soluble Salts of. — Sulphate of soda or magnesia. 

Lead, Carbonate of. — Sulphate of magnesia with weak vinegar. 

Lime. — Vinegar and water. 

Mercury. — Soluble Salts of. — White of egg ; flour and water. 

Morphia, and the alkaloids generally, finely divided animal charcoal, 
tannin ; dilute tincture of iodine. 

Muriatic Acid. — See Acids. Mineral. 

Xitric Acid. — See Acids, Mineral. 

Opium and its Preparations. — No antidote. Treatment by the 
stomach-pump or mustard emetics, cold affusion, and forced 
exercise. Then strong coffee. In extreme cases, electro-magnetism 
and artificial respiration. 



656 ANTIDOTES TO THE PRINCIPAL POISONS. 

Oxalic Acid and the Soluble Oxalates. — Common chalk, whit- 
ing, prepared chalk, or compound chalk powder, magnesia. 

Phosphorcs. — Xo antidote. Magnesia diffused through water, or 
suspended in mucilage, may be given with advantage. 

Potash and its Carbonates. —Vinegar and water ; oil. 

Silver, Nitrate of. — Solution of common salt. 

Soda and its Carbonates. — Vinegar and water ; oil. 

Strychnia. — Chloroform, nicotine and conia, and tincture of aconite. 

Sulphuret OF Potassium. — Weak solution of chlorine. 

Sulphuric Acid. — See Acids, Mineral. 

Tartar Emetic. — Tannin ; tincture of bark, kino, or catechu ; strong 
tea. 

Zinc, Chloride and Sulphate of. — A dilute solution of carbonate 
of soda. 



( 657 ) 



CLASSIFICATION OF EEMEDIES AND FOKMUL^L 



Except when otherwise stated, the medicines prescribed in the follow- 
ing Formulae are those of the British Pharmacopoeia of 1867, and the 
imperial weights and measures adopted in that work are of course 
employed here. They are as follows : — 

Weights. 

1 pound lr)j = 16 ounces — 7000 grains. 
1 ounce jj = 437 '5 ,, 

Measures. 

1 gallon . Cj = 8 pints . . = Oviii. 

1 pint . Oj = 20 fluid ounces = f Jxx. 

1 fluid ounce f Jj - 8 drachms . = 5viii. 

1 drachm gj = 60 minims . = rr| lx. 

The doses are full doses for Adult Males, unless otherwise stated. 
For Adult Females they must be somewhat diminished, according to 
the judgment of the practitioner. In prescribing for younger 
persons of either sex, the subjoined table of doses may be safely 
followed. The dose for the Adult Male is taken at 60 grains or 
60 minims. 

Gr. or v\, 

1 3 years . . . . x. or | 

J 1 year .... vi. or $ 

6 months .... iii. or J g 

3 months . . . . ii. or ^ 

Except when otherwise indicated, each prescription is for a single dose, 
and such as may be repeated every four or six hours. 



Adult male 


Gr. or v\. 

lx. or 


1 4 years . 


. xxx. or 


7 years 


. xx. or 


5 years 


. xv. or 



STIMULANTS. 



1. GENERAL STIMULANTS. 
(Including Diffusible Stimulants and Stimulant Antispasmodics.) 

1. Ammonias carbonas Dose gr. iii. to gr. x. 

2. Liquor ammonias ,, TYL v. — TY\, x. 

3. Liquor ammonias acetatis „ 5 ii. — §vi. 

4. Liquor atropias sulphatis and liquor atropias ,, rr\ iii. — TY\v. 

2 U 



658 



STIMULANTS. 



TY|XX. to 31. 

5ss. — 3ii. 
gr.x. — xxx. 

rrtxx.— 31. 
5ss. — 3«. 



Tr\iii. — XXlv 



TY^xx. — TYJxl. 



5. Spiritus ammoniae aromaticus .... Dose 

6. Spiritus chloroform i ,, 

7. Ammonise hydrochloras ,, 

8. -Ether (sulphuricus) 

9. Spiritus aetheris nitrosi 

10. Mistura spiritus vini Gallici 

11. Oleum anethi, anthemidis, anisi, carui, cary-' 

ophylli, cinnamomi, juniperi, sabinae, La- 
vandulae, terebinthinae, rorismariui, men- 
thaj [viridis et piperita?), rnyristicae, pi- 
rn entse, cajuputi, pulegii, limonis, rutae. 

12. Spiritus camphorse, cajuputi, armoracisecom- 

positus, juniperi, menthae, piperita?, rnyr- 
isticae, Lavandulae, and rorismarini . 

13. Tinctura aurantii ; assafcetidae ; belladonnas ;' 

benzoini ; bucco ; capsici ; cardamomi com- 
posita ; cascarillse ; castorei ; chlorofovmi 
composita ; cinchonas flavae ; cinchonae 
composita; cinnamomi; gentianae corn-j> „ 3 SS, ~ 
posita ; guaiaci ammoniata ; lavandulae 
composita, limonis : lupuli ; myrrhae ; 
serpentariae ; sumbul ; Valerianae ; Valeri- 
anae ammoniata ; and zingiberis . 

14. Camphora 

15. Aqua camphorse 

16. Moschus 

17. Assafcetida 

18. Kreasotum 

19. Phosphorus 

20. Sumbul radix 

The aqua camphorse, the distilled waters (aqua anethi, carui, faeni- 
culi, cinnamomi, pulegii, pimentae, menthae — viridis and piperitae), and 
the tonic infusions (infusum anthemidis, aurantii, bucco, calumbae, cary- 
ophylli, cascarillae, cinchonae flavae, cuspariae, gentianae compositum, 
chiratse, kramerise, lupuli, quassiae, serpentariae, and Valerianae), are ap- 
propriate vehicles for the stronger stimulants, and the syrups (especially 
the syrupus aurantii and zingiberis) may be used to impart an agreeable 
flavour. 

Stimulants in the form of Draught. 



jr r 


v. 




0T. X. 


5i- 






5"- 


g r 


V- 




XX. 


Zr. 


v. 




XX. 


<a 


1. 


— 


rr\ii. 


g 1 *. 


8 




4 


gr. 


X, 


— 


gr. xx 



1. R. Ammonise carbonatis gr. x. i 

Liq. ammoniae acetatis giii. 
Syrupi aurantii 5J. 
Aquae J- Ss ' Fiat haustus. 

2. R. Sp. ammoniae aromatici 

f 5 ss. 
Trae. lavandulae compositae 
3i. 



Syrupi aurantii f 3L 
Aquae cinnamomi ^i. M. 

3. R. Trae. guaiaci ammoniatae 

f 3ss. 
Decocti cinchonae flavae, 
f 31SS. 1. M. flat haustus. 

4. R. Misturae guaiaci Jss. 

Amnion, carb. gr. viii. M. 



STIMULANTS. 



659 



5. R. Spiritus aether is 5J. 

Tincturae lavandulae co. 5L 
Infusi Valerianae 51s s. M. 

6. R. Spiritus astheris TTl xxx. 

Spiritus aramon. arom. 5SS. 
Spiritus cajuputi jss. 
Infusi cascarillae ^iss. M. 

7. R. Camphor ae gr. y. 

Spiritus rectirlcati TY\j. 
Reduce to a powder, and add — 
Pulveris acaciae 5ss. 
Syrupi limonis 5ss. 
Aquae menthae viridis Jiss. 

8. R. Moschi gr. xx. 

Pulv. tragacanthae co. 55s. 
Aquae cinnarnomi ^iss. M. 

9. R. Tr. Valerianae ammoniatae. 

Tincturas assafcetidae aa 5J. 
Aquae pimentae Jiss. M. 

10. R. Tincturae sumbul 5J. 

Trae. layandulae comp. 3S. 
Infusi ralerianae ^iss. 

11. R. Radicis armoraciae excisae 



Baccaejunipericontusse Jiii. 

Vini Xerici Oiii. 
(Digest for one week, and strain. 
Dose, a wine-glassful. Nonr 
officinal.) 

12. R. Olei terebinthinae 5iv. 

Ovi vitelli unius. 

Sacchari ^ss. 

Aquae £y. M. (|—|0 
(The whole, mixed with a pint of 
gruel, mav be also used as an 
enema in certain cases.) 

13. R. Kreasoti TY\,i. 

Misturae amygdalae Jiss.M. 

14. R. Tincturae belladonnae TY\xx. 

Ammonia carbonatis gr. y. 
Misturae camphorae Jiss. M. 

15. R. Phosphori gr. v. 

Olei oliyae f Jss. 
Digest a fortnight in the dark, 
and add — 

Olei carui TY\iY. 
(Dose, 15 drops cautiously in- 
creased, in milk. Non-officinal. , 



Stimulants in the form of Bolus, and Powder. 

16. R. Terebinthinae Canadensis 
gr. y. 
Pulyis glycyrrhizae, quan- 
tum sutficit. Fiat bolus. 



17. R. Camphorae. 

Moschi aa gr. x. M. 
(The powder to be taken in barley 

water ; in hysteria.) 



. STIMULANTS ACTING LOCALLY UPON CERTAIN 
SYSTEMS OR PARTS. 

Through the Nerves ox the Muscular System. 

(a.) On the Voluntary Muscle. 

1. Extractum nucis vomicae . dose gr. J, gradually increased to gr. ii. 



2. Strychnia . 

3. Liquor strychniae . . ,, 

18. I£. Strychniae gr. i. 
Dissolve in a few drops of alcohol 
and then mix intimately with | 



gr. i, cautiously increased to gr. 



WtT-( = Agr.) 



m*. = in- 



sufficient extract of gentian and 
liquorice powder to make 24 
pills (one for a dose). 



660 STIMULANTS TO GENITO-URLNARY ORGANS. 

In the form of Mixture. 
19. R. Liquoris strychniae V(\y. I 20. R. Liquoris strychniae, TY^iii. 
Aq. inenthae piperitae £iss. | Quiniae disulphatis gr. ii. 

ft. H. Acidihydrochloricidil.TT^v. 

Aquae cinnamomi ^iss. ft.H. 
(6.) On the Involuntary Muscle. 
Ox the Uterus. 

1. Extractum ergotae liquidum ; dose, TYVxv. to 3L 

2. Infusuru ergotae ; dose, ^i. to ijii. 

3. Tinctura ergotae ; dose, 3L to 3 ii. 

Ox the Urinary Organs. 
Cantharis vesicatoria. Dose in powder gr. J, cautiously increased. 
Cantharidis tinctura. ,, TY\x., cautiously increased. 

. Sabinae tinctura. ,, TY^xx. — gi. 

Sabinae oleum. „ TYl i. — v. 

In the form of Draught. 



21. R. Tinct. cantharidis TY^x. 

Infusi. quassiae ^iss. M. 

22. R. Tincturae sabinae 35s. 

Spiritus myristicae 35s. 
Infusi Bucco ^iss. M. 

23. R. Tinct. cantharidis TYlx. 



Tinct. ferri perchloridi 

Aquae pimentae Jiss. M. 

24. R. Olei sabinae Trlji. 

Spiritus chloroformi 3SS, 
Aquae Jiss. M. 



On the Mucous Membranes. 

Copaiba dose TY^xx. to 3H. . 

Copaibae oleum ,, Vf\v. — TT1 xx. 

Purvis cubebae ., gr. xx. — gr. xxx. 

Cubebae oleum „ TY\v. — TY^xx. 

Confectio piperis „ gi'. — c. 

Balsamum Peruvianum ,, TY^xv. — TY^xxx. 

Confectio terebinthinae ,, gr.xxx. — 1. 

Balsamum tolutanum „ gr. xx. — gr.xxx. 

Syrupus tolutanus „ gi. — 3ii. 

Tinctura tolutana „ 3SS. — gi. 

Tinctura benzoini composita ... „ 3SS. — 3i. 

Oleum terebinthinae' „ TY^x. — 3i. 

Terebinthina Canadensis ,, gr. v. — • xx. 

In the form of Draught, $c. 



25. R. Copaibae 3ss. 

Liquoris potassse TY^x. 

Syrupi tolutani 3SS. 

Aq. Menth. pip. ^iss fc M. 

26. R. Pulvis cubebae 3SS. 

Syrupi papaveris 3J. 
Aquae cinnamomi Jss, M. 



27. R. Confectionis piperis. 

sennae.aa 3J. M. 

28. R. Tinct. benzoini co. 3ss. 

Syrupi tolutani 3J. 
Pulv. tragacanth gr. c. 
Aquae ^iss. M. 



CAUSTICS — VESICANTS — RUBEFACIENTS. 



661 



In the form of Pill or Powder. 



29. R. Copaiba. 

Magnesia aa gr. x. fiant boli 
duo. 



Vapor chlorinii. 



30. R. Pulveris cubebas 3L 

Sodas bicarbonatis 3ss. fiat 
pul vis. 

Inhalations. 
Vapor kreasoti. Vapor iodinii. 



3. EXTERNAL AND LOCAL STIMULANTS. 



1. Caustics. 

Acidum nitricum. Acidum 
sulphuricum. Acidum ar- 
seniosum. 



4. Liquor ammonias fortior. 

5. Liq. hydrargyri nitratis acidus. 

6. Soda caustica. 
Argenti nitras. 7. Potassa caustica. 

Cupri sulphas. 8. Zinci chloridum et sulphas. 

2. Vesicants. 

4. Linimentum crotonis. 

5. Oleum sinapis. 



Charta epispastica. 
Emplastrum cantharidis. 
Liquor epispasticus. 

3. Rubefacients. 



Acetum cantharidis. 

Acidum aceticum ; hydrochlo- 
ricum dilutum ; nitricum 
dilutum ; nitro-hydrochlo- 
ricum dilutum ; sulphuri- 
cum dilutum ; sulphuro- 
sum. 

Armoracias radix. 

Linimentum ammonias ; cam- 
phorae ; camphorae eompo- 
situm ; chloroformi ; hy- 
drargyri ; iodinii ; saponis ; 
sinapis compositum ; tere- 
binthinae ; terebinthinae ace- 
ticum. Emplastrum am- 
moniaci cum hydrargyro ; 
galbani ; picis ; resinae ; ca- 
lefaciens. 

Liquor ammonias : calcis chlo- 
rinatae ; sodas chlorinatas. 

Mezeiei extractum asthereum. 

Oleum cajuputi ; caryophylli ; 
crotonis ; rutas ; rorisma- 
rini ; terebinthinas. 

Phosphorus. 



9. Pix Burgundica ; liquida ; 
resina ; terebinthina Cana- 
densis. Thus America- 
num ; balsamum Peruvia- 
num ; balsamum toluta- 
num. 

10. Sinapis cataplasma. 

11. Spiritus ammonias aromaticus ; 

cajuputi; camphorae; chlo- 
roformi ; rectiricatus ; ten- 
nior; rorismarini. 

12. Sulphuris iodidum. 

13. Tinctura arnicas; cantharidis; 

capsici ; iodinii ; pyrethri. 

14. Unguentum antimonii tarta- 

rati ; calomelanos ; hycirar- 
gyri iodidi rubri ; hydrar- 
gyri nitratis ; hydrargyri 
oxidirubi; hydrargyri am- 
moniati ; iodinii composi- 
tum ; kreasoti ; potassii 
iodidi ; resinas ; elemi ; can- 
tharidis ; sulphuris ; tere- 
binthinas; sabinas. 

15. Zinci sulphas. 



662 STIHUIiANT LOTIONS, COLLYRIA, BATHS, LINIMENTS. 



Stimulant Lotions, 

31. R. Acidi nitrici. 

Acidi hydrochlor. aa TY\xx. 
Aquae t* Jviii. M. fiat lotio. 

32. R. Acidi sulphurici diluti . 

Aquas destillate aa f ^ss. M. 

33. R. Acidi sulphurosi. 

Aquae, partes aequales. M. 

34. R. Liq. ammoniae fort, f Ji. 



Spiritlis rorismarini f Jss. 

Tinct. camphorae f rii. M. 

(A highly-stimulant application.) 

35. R. Ziuci sulphatis gr. vi. 
Spiritlis rorismarini. 
Tincturae Lavandulae com- 

positae aa 5iss. 
Aquae f Jvss. M. 
(Red wash.) 



40. 



41. 



Stimulant Collyria. 

39. R. Zinci sulphatis gr. ii. 
Vini Opii 3ii. 
Aquas ji. Solve. 
R. Hydrarg. bichloridi gr. J. 
Aquaedestillataef^i. Solve, 
R. Potassii iodidi gr. vii. 
Iodinii gr. iii. 
Aquae destillatae Oi. Solve 

Stimulant Baths. 

42. R. Acidi hydrochlorici Jii.-Jv. 

Aquae q. s. M. 

43. R. Acidi nitro-hydrochlorici 

diluti 0}. 



36. R. Aluminis gr. v. 

Aquae Ji. Solve. 

37. R. Argenti nitratis gr. i. 

Aquae Ji. Solve. 

38. R. Cupri sulphatis gr. v 

Aquae £i. Solve. 



Aquae tepidse (96°) q.s. M. 
(The acid may be used in the pro- 
portion of Jvi. to 8 gallons, as 
a bath or lotion.) 

44. R. Kreasoti 5H. 
Glycyrini 3U. 
Aquae calidae Cxxx. M. 

Stimulant Liniments. 



45. R. Iodinii 311. 

Liquoris potassae f ^ii. 
Aquae calidae Cxxx. M. 



46. R. Hydrargyriperchlor.gr. c. 
Acidi hydrochlorici ^i. 
Aquae Cxxx. Solve. 



47. R. Sulphuris precipitati Jii. 
Sodae hyposulphitis Ji. 
Acidi sulphurici diluti Jss. 
Aquae Cxxx. M. 



48. R. Liquoris ammonias f Jss. 

Linimenti saponisf Jiss. Af. 

49. R. Tincturae cantharidis f §ss. 

Linimenti saponis f Jiss. 
(A good application to chilblains.) 

50. R. Camphorae gr. c. 

Olei terebinthinas f Jss. 
Linimenti camphorae co. *ss 
M. 

51 . R. Pulvis seminis sinapis gr. c. 



Acidi acetici f ^ss. 

Olei terebinthinas f Jss. M. 

52. R. Antimonh" tartarati gr. c. 

Aquas rosas f Jii. 
Tincturae cantharidis f Ji.M. 

53. R. Acidi sulphurici jiss. 

Olei terebinthinas ^ss. 
Olei olivas f ^iss. M. caute. 

54. R. Olei cajuputi f ^iss. 

Linimenti camphorae com- 
positi f Jss. Id. 



STIMULANT OINTMENTS, GARGLES, ENBMATA. 



663 



Stimulant Ointments. 



55. R. Argenti nitratis gr. x. 

Unguenti simplicis gr. c. M. 

56. R. Olei crotonis 31. 

Adipis ^i. M. fiat unguen- 
tum. 



57. R. 

58. R. Camphorae gr. xv. 



, Kreasoti TY\y.— 
Adipis ^ss. M. 



Glycerini ^ 
Adipis J.'M. 



59. R. 



Cainphorae gr. xx. 
Unguenti h ydrargyriJss.M. 



60. R. Phosphori gr. ii. — v. 

iEtheris q. s. 
Dissolve, then add — 
Camphorae gr. xx. 
Unguenti simplicis Jss. M. 

61. R. Potassae carbonatis Ji. 

Sulphuris precipitati Jii. 
Adipis Jiv. M. 

62. R. Picis liquidae Jiv. 

Cerae flavae Jss. 
Sulphuris ^i. M. 

63. R. Cupri sulphatis gr. xxx. 

Acidi sulphurici diluti TY^x, 
Adipis gi. M. 



Stimulant Gargles. 



64. R. Tincturae capsici Jss. — ^i. 

Syrupi 11 

Aquse rosas Jvi. M. 

65. R. Yini rubri Lusitanici ^vi. 

Tincturae capsici Jss. M. 

66. R. Acidi hydrochlorici dii. Jss. 

Mellis rosae J- 

Decocti hordei ^viss. M. 

67. R. Acidi nitro-hydrochlorici 

dil. 5iii. 
Decocti hordei Jviss. 
Mellis rosae Ji. 



68. R. Infusi rosae acidi Jiiiss. 

Tincturae myrrhae ^ss. 
Sacchari ^ss. M. ft. garga- 
risma. 

69. R. Mellis boracis Jiss. 

Aquae Jriss. M. 

70. R. Mucilaginis acaciae Jviiss. 

Olei terebinth inae ^ss. M. 

71. R. Potassae chloratis gr. c. 

Acidi hydrochlorici 3ii. 
Aquae f gviiss. 



Stimulant Enemata 
Enema assafcetidae. Enema terebinthina? 

72. R. Olei terebinthina?. 

Tincturae assafcetidae a Jss. 
Decocti hordei Oj. M. 



73. R. Spiritus rectificati Jss. 

Infusi serpen tariae Jiiss. M. 



Stimulant Powders. 



74. R. Cupri subacetatis. 

Pulvis sabinae ana Ji. M. 

75. R. Pulvis sabinae gr. c. 



Aluminis usti. 
Hydrargyri oxidi rubri 
ana gr. xv. M. 



664 



NARCOTICS, ANODYNES, AND SEDATIVES. 



76. R. Sulphuris Jss. — Jiss. 

Iodinii gr. xx. — 1. M. 
(A twelfth part of this powder to 
be used at a time. The vapours 
of sulphur and of iodine may 
also be used separately, in ob- 
stinate cutaneous diseases.) 

77. R. Calomelanos gr. xv. — xxx. 



Fumigations. 



78. R. Manganesii binoxidi ^i. 

Sodii chloridi Jiii. 
Mix, then add — 

Acidi sulphurici f £i. 

Aquas f ^ii. 
(Chlorine is given off from this 
mixture on applying heat.) 

79. R. Hydrarg. sulphureti 



err. xx. — xxx. 



4. NARCOTICS, ANODYNES, AND SEDATIVES. 

(Including Antispasmodics belonging to these Classes.) 

.Ether, dose lY^xx.— 51. ; vapor 3J.— -31J. _ 

Acidum hydrocyanicum dilutum, dose Tr\iii. — TT\yiii. 

Aconiti extractum, dose gr. i. — gr. ii. Aconiti tinctura, dose VC\y. 

— TT|xv. The doses to be cautiously increased. Aconitia (only 

used externally). 
Atropise liquor, dose Tr\iii. — v. A. sulphatis liquor, TTtiii. — v. 
Belladonna extractum, dose gr. J — gr. i. Tinctura belladonnas, 

dose VC\y, — TY^xx. 
Bismuthi carbonas gr. v. — xx. ; subnitratis gr. v. — xx. ; Liquor 

B. et ammonias citratis 3ss. — 3ji. ; trochisci (gr. ii. subnitrate 

in each) i. — vj. 
Cannabis Indicas extractum, dose gr. | — gr. i. ; tincturas cannabis 

Indies TTtv. — 3ss. 
Cerii oxalas, dose gr. i. — gr. ii. 

Chloroform! spiritus, dose TY^xv. — 3H. ; vapor 3J. — 3ii. 
Colchici cormus et semen. Extractum colchici, gr. \ — gr. ii. 

Extra cti colchici acetici, gr. \ — gr. ii. Vinum colchici, Tllx. 

— 3ss. Tinctura colchici seminum ff\x. — 3ss. 
Conii extractum gr. v. — gr. xxx. Tinctura Conii fructiis, inert. 

Succus Conii, Tr\xv. to ^j. 
Digitalis folia, gr. J — gr. iss. Infusum Digitalis, 3H. — 3iv. 

Tinctura Digitalis, Tr\x. — 3ss. Digitalinum, gr. ^ — ^. 
Hyoscyami folia, dose gr. v. — gr. x. Extractum Hyoscyami, 

dose gr. v. — xx. Tinctura Hyoscyami, dose Vf]x. — 3L 
Lactucae extractum, dose gr. v. — xv. 
Lauro-cerasi aqua, Tr\v. — xxx. 
Lobelias inflates pulvis, dose gr. i. — gr. v. Tinctura Lobelias, dose 

TT\x. — 3ss. Tinctura Lobelias astherea, dose Tr\x. — 3ss. 
Morphia, dose gr. J — gr. i. Morphias hydrochloras, dose gr. J — 

gr. i. Liquor morphias hydrochloratis (gr. i. in 3H.), dose 

TlOxv. — 3ii. Trochisci morphias (gr. i. in 36 lozenges), dose 

1 to 15 during the day. Trochisci morphias et ipecacuanhas 

(gr. l. in 36 lozenges). 



NAKCOTICS, ANODYNES, AND SEDATIVES. 



665 



16. Opium, dose gr. i. — gr. vi. 
Extra ctum opii, dose gr. J — gr. ii. 

Enema opii (3ss. of laudanum = gr. ii. opium, to starch f ^ii.). 
Extractum opii liquidum (gr. i. of extract in about TY^xxiii.). 
Pilula saponis composita (gr. i. in gr. v.), dose gr. v. — gr. x. 

styracis composita L. (gr. i. in gr. v.), dose gr. v. — gr. x. 

plumbi cum opio (gr. i. in viii.), dose gr. iv. — viii. 

Pulvis cretse aromaticus cum opio (gr. i. in xl.), dosegr. x.— xl. 

— kino compositus (gr. i. in xx.), dose gr. v. — xx. 

ipecacuanhas compositus (gr. i. in gr. x.), dose gr. y. — xv. 

opii compositus (gr. i. in x.) gr. ii. — v. 

Tinctura opii (gr. i. in Ti\xv.), dose Vf\v. — 3ss. 

camphoras composita (gr. i. in ^ss.), dose 3ss. — f 5SS. 

Trochisci morphias (^ gr. morph. hydroch. in each) i. — yj. 

■ morphias et ipecacuanhas (-L g r . and ^ gr.) i. — vj. 

opii (gr. i. extract in 10 lozenges), 1 to 5 during the day* 

Vinum opii (gr. i. in nrtxxiii.), dose ty\v. — xl. 

17. Papaveris syrup us dose, 3L ; extractum, gr. ii. — v. 
Physostigmatis extractum gr. -jL — J. 

18. Stramonii folia et semina, dose gr. ii. — gr. x. Extractum Stra- 

monii, dose gr. J — gr. iii. Tinctura Stramonii, dose TT\x. — xx. 

19. Tabaci enema (tobacco gr. xx. — boiling water f ^viii.). Dose, the 

whole. 

20. Veratria, dose gr. L — 1. 



Narcotics, $c, in the form 

80. R. Tincturas opii TY\xx. 

Aquas cinnamomi. 
Aquas pur as aa 3vi. M. 

81. R. Potassas bicarb, gr. xx. 

Aquas menthas yiridis f Ji. 
Tincturas opii TT^xxv. M. 
(To be taken with Jj. of lemon- 
juice.) 

82. R. Tincturas opii TT\xxx. 

Liq. ammonias acetatis 3!. 
Aquas cinnamomi. 
Syrupi tolutani aa f ^ss. M. 

83. R. Acidi sulphurici diluti TY\xv. 

Tincturas opii TT\x. vel tinc- 
turas hyoscyami 3ss. 
Tincturas digitalis TY\x. 
Infusi quassias Jiss. M. 

84. R. Acidi hydrocyanici diluti 

TYlv. 

Misturas amygdalas ^iss. M t 

85. R. Bismuthi carbonatis gr. x. 



87. R, 



88. R 



of Draught. 

Acidi hydrocyanici diluti 

TY\v. 
Mucilaginis acacias f Ji. 
Syrupi aurantii 3L M. 
Acidi hydrocyanici diluti 

TY\v. 
Tincturas digitalis TY\x. 
Aquas camphoras. 
Aq. cinnamomi aa, 3vj. M. 
Tincturas belladonnas TY^x. 
Syrupi papaveris 3J. 
Spiritus chloroformi Tr\xx. 
Aq. menthas piperitas liss. 

M. 
Potassas nitratis gr. c. 
Tincturas digitalis TY\x. 
Liq. ammonias acetatis 3ii. 
Syrupi hemidesmi 3J. M. 
Aquas destillatas Jiss. 
, Tras. seminis colchici TY\xv. 
Infusi digitalis 3iv. 
Aquas cinnamomi ^iss. M. 



666 SEDATIVE APPLICATIONS. 

Narcotics, §c, in the form of Pill. 

90. R. Extracti conii gr. x. Ext. hyoscyami anagr.ii.ss. 

Bismuthi subnitratis gr. v. Sp. rectificatus q. s. ft. pil. 

Fiant pilulas duas. 

94. R. Extracti hyoscyami gr. v. 

91. R. Extracti belladonnas gr. }. \ Extracti cJnii gr. x. ft. pil. 



Pulvis ipecac, c. gr. x. 



M. 



M. fiant pilulas duas. 95# j> Extract, conii gr. viii. 

Pulv. ipecacuanhas gr. ii. 

92. R. Pulvis digitalis. Morphia hydrochlor. gr. \ 

- — sci 11a?. ^ j n pjiuias d uas divide. 

Ext. hyoscyami aa gr. v. 
M. in pilulas tres divide. 96. R. Cerii oxalas gr. ii. 

Extracti lactucae gr. viii. 

93. R. Camphorae pulvis. Fiant pilulae duae. 

Narcotics, fyc, in the form of Pov:der. 






97. R. Pulv. ipecac, comp. gr. i. 
Sacchari gr. xx. M. 

(Divide into four powders. For 
young infants. Each powder 
contains jL g r# f opium.) 



98. R. Camphoras gr. iii. 

Spirit, vin. rect. TT\n. 
Palv. ipecac, c. gr. v. M. 
(A powder to be taken at bed- 
time.) 



Sedatives in the form of Vapour. 
1. Vapor acidi hydrocyanici. 2. Vapor conii. 



5. EXTERNAL SEDATIVE APPLICATIONS. 

1. Cataplasma conii. 

2. Chloroformum. 

3. Decoct um papaveris. 

4. Emplastrum belladonnas (Resin and B. p. as.) ; opii (gr. j. of 

powder in gr. x.). 

5. Extractum aconiti ; belladonnas ; conii ; opii ; opii liquidum. 

6. Linimentum aconiti ; belladonnas ; chloroformi ; opii (gr. i. in 3ss.). 

7. Unguentum aconitias (gr. viii. in Ji.) ; atropias (gr. viii. in ^i.) ; 

belladonnas (gr. lxxx. to Ji.) ; gallas cum opio (gr. i. in about 
gr. xiv.) ; veratrias f gr. viii. in Ji.). 

Several preparations of the Pharmacopoeia enumerated among nar- 
cotics and sedatives (pp. 664, et seq.) also admit of external application. 
All substances, too, which produce cold by evaporation or otherwise, 
may be said to belong to the class of sedatives. 

Sedative Lotions. 
99. R. Potassas carbonatis gr. xii. I 100. R. Tincturas opii. 

Tincturas opii TY\xxx. Acidi hydrocyanici, dil. 

Aquas 3L M. fiat lotio. | aa partes asquales. 

M. fiat lotio. 



SEDATIVE APPLICATIONS AND ENEMATA. 



667 



101. R. Liquoris potassae gii. 

Acid hydrocyanic! dil. 

^iss. 
Misturae amygdalae f ^viss. 
M. fiat lotio. 

102. R. Extracti belladonnas gr. ii. 

Extracti opii ana gr. ii. 
Aquae ^i. M. fiat lotio. 



103. R.* Potassii cyanidi gr. x. 

Mist, amygdalae Jvi. M. 
(* Non-officinal.) 

104. R. Extracti conii gr. xl. 

Extracti opii gr. iii. 
Aquae ferventis Ji. M. 

105. R. Vini opii TY^xx. 

Aquae laurocerasi Jj. M. 



Cold Applications. 



106. R. Ammoniae hydrochloratis, 

Sodii chloridi, 

Potassae nitratis aa ^ii. 
Mix, and dissolve in water. (A 
frigorific mixture, applicable 
whenever intense cold is re- 
quired.) 



107. R. Ammoniae nitratis. 

Aquae aa lb. i. Solve. 

(In winter, mix equal parts of snow 
and common salt. In summer, 
equal parts of pounded ice and 
salt.) 



Sedative Fomentations, 

108. R. Opii gr. c. I 109. R. Extracti belladonnae gr. 1. 

Aquae ferventis Oi. M. Aquae ferventis Oi. 



M. 



Sedative Ointments, 



110. R. Plumbi acetatis gr. xxx. 
Acidhydrocyanici dil. 3iii. 
Unguenti simphcis Jiii.M. 



111. R. Potassii cyanidi gr. xii. 
Olei amygdalae 3I1. 
Unguenti simplicis Jii. M. 



Sedative Enemata and Suppositoria. 

Enema opii ; E. tabaci. 
Suppositoria morphiae. S. plumbi composita. 



112. R. Pilulae saponis co. gr. v. 
Fiat suppositorium. 



113. R. Liquoris atropiae TY\v. 
Decocti amyli ^iij. 
Fiat enema. 



6. STIMULANTS, IN COMBINATION WITH NARCOTICS, 

SEDATIVES, AND ANODYNES. 

(Including Stimulant and Anodyne Antispasmodics.) 
In the form of Draught. 



1 14. R. Tr. Valerianae ammon. 33s. 
Spirittis aetheris gi. 
Tincturae hyoscyami 3ss. 
Aquae camphorae f ^i. M. 



115. R. Tincturae digitalis TY\xv. 
Sp. ammon. comp. 3ss. 
Aquae camphorae 31 ss. M. 



668 



STIMULANTS WITH SEDATIVES. 



116, 



117 



121 



122. 



R, Moschi gr. x. ; 118. 

jEtheris. 

Tincturae opii aa n\xx. 
Aquas cinnamomiif^i. M. 119 



R. Aquas camphorae ^iii. 
Spiritus astheris. 
TiDct. camphor, compo- 120. 

sitae. 
Syrupi papav. aa 5L M. 

In the form of 
R. Pil. assafcetidas compositas 
Camphorae a gr. v. 
Fiant pilulae duas. 

R. Castorei gr. v. 

ril. sapoms comp. gr. in. 1 -^ 
Olei menthae pulegii gttj 
Fiant pilulae duse. 



R. Tinct. opii 3ss. 

Mist, camphorae f Ji. M. 

. R. Tincturae opii TYlx. 
Spiritus setheris TY^xl. 
Aquae camphorse ^iss. M. 



123. R. Camphorae gr. v. 



R. Tinct. colchici seminum. 
Spir. ammonias co. aa 5SS. 
Infusi serpentariasjiss. M. 

phi. 

Olei cajuputi Tr\ii. 
Pulveris opii gr. ss. 
Estracti hyoscyami gr. v. 
Fiant pilulae duas. 

, R. Kreasoti TY\i. 

Pilulae saponis composi- 

tas gr. iii. 
Ext. hyoscyami gr. viii. 
Fiant pilulae duas. 



7. EXTERNAL APPLICATIONS (Stimulant and Sedative). 



125. 
126. 

127. 

130. 



R. Linimentum opii Jiss. 

R. Olei cajuputi f Jiss. 
Tincturae opii f ^ss. 
Lin, terebinthinas Jii. M. 

R. Linimenti belladonnas. 
Linimenti chloroformi 
partes asquales. M. 



128. R. Tincturae cantharidisf^ss. 

Linimenti camphorae f J. 
Liquoris ammonias 3L 
Tincturae opii 3iii. M. 

129. R. Olei crotonis Tr\x. 

Linimenti saponis co. Jj. 
Tincturae opii f Jss. M. 



Exemata (Stimulant and Sedative). 



R. Tincturae assafoetidas f ^ss. 
Tincturae opii 3L 
Decocti hordei Oss. M. 



131. R. Camphorae gr. xx. 

Olei terebinthinae f Ji. 
Decocti hordei Oss. M. 



8. TOXICS. 

1. MIXER AL. 

Mineral Acids. 

1. Acidum hydrochloricum dilutum 

2. Acidum nitricum dilutum . 

3. Acidum nitro-hydrochloricum dilutum 

4. Acidum phosphoricum dilutum . 

5. Acidum sulphuricum aromaticum . 

6. Acidum sulphuricum dilutum . 



. dose TTl x. to TTtxxx. 

. „ TY\x. — TTTxxx. 

. „ rrvx. — rrixxx. 

. „ TYlx. — Tr\xxx. 

. „ rrix. — rr^xxx. 

. „ rrix. — rrixxx. 



MINERAL TOXICS. 



669 



Preparations of Iron, 

7. Ferri et ammoniae citras 

8. Ferri arsenias 

9. Ferri carbonas saccharata 

10. Ferri iodidum 

11. Ferri et quiniaa citras 

12. Ferrum tartaratum . 

13. Ferri oxidum magneticam 

14. Fern peroxidum humidum 

15. Ferri peroxidum hydratum 

16. Ferri phosphas 

17. Ferri sulphas 

18. Ferri sulphas exsiccata . 

19. Ferri sulphas granulata . 

20. Ferrum redactum 

21. Liquor ferri perchloridi . 

22. Liquor ferri pernitratis . 

23. Mistura ferri aromatica . 

24. Mistura ferri composita . 

25. Pilula ferri carbonatis . 

26. Pilula ferri iodidi (gr. v. — gr. ij nearly Fel) 

27. Syrupus ferri iodidi (3L = gr. ivss. Fel) 

28. Syrupus ferri phosphatis . 

29. Tinctura ferri acetatis 

30. Tinctura ferri perchloridi . 

31. Trochisci ferri redacti (1 gr. in each) 

32. Vinum ferri ; et v. f. citratis 

33. Emplastrum ferri. 



. dose gr. y. 


to gr. x. 


?> 


§?•■ T6 


— S r - T5- 


»3 


gr. x. 


— gr. c. 


JJ 


gr. v. 


— gr. x. 


• ?? 


gr. v. 


— gr. x. 


55 


gr. y. 


— gr. x. 


V 


gr. y. 

gr. cc. 


— gl\ XXX 

— Jss. 


• 5J 


gr. y. 


— oj- 


J5 


gr. y. 


— gr. xx. 


>> 


gr. i. 


— gr. x. 


• JJ 


gr. i. 


— gr. y. 


JJ 


gr. i. 


— gr. x. 


J5 


gr. i. 


— gr. x. 


J? 


TY^x. 


— TTtxxx. 


• >> 


TT1V. 

5- 

5j. 


— TY\xx. 

— So* 


?> 


gr. y. 


— gr. xx. 


) „ 


gr. v. 


— gr. xx. 


J5 


3ss. 


— 5 !i - 


!9 


5i- 


— o lv - 


» 


TTtv. 


— Tr\xxx. 


• 5> 


TT1X. 
i. 


— TY|xxx. 


• ii 


5J- 


— o iv - 



Preparations of Zinc. 

34. Zinci acetas dose gr. ii. to gr. y. 

35. Zinci carbonas „ gr. ii. — gr. y. 

36. Zinci oxydum ,, gr. ii. — gr. y., or more. 

37. Zinci sulphas „ gr. ii. — gr. y., or more. 

38. Zinci ralerianas „ gr. i. — gr. y. 

Preparation of Copper. 

39. Cupri sulphas dose gr. J to gr. ii. 



Preparations of Arsenic. 

40. Acidum arseniosum dose gr. ^L to gr. I. 

41. Ferri arsenias „ gr. ^ to gv. J. 

42. Liquor arsenicalis (gr. iY. inf Ji., or i gr. in TT^v.), dose VC]r. — x. 

43. Liquor arsenici hydrochloricus (gr. iY. AS0 3 . in ^j., or jjg in TI^y.), 

dose TY\ii. — TT\Yiii. 

44. Liquor soda? arseniatis (gr. iY. inf Ji., or J ? gr. inlTLv.), TY^y. — x. 



670 



VEGETABLE TOXICS. 



Preparations of Silver . 

45. Argenti oxydum dose gr. j to gr. i. 

46. Argenti nitras „ gr. J — gr. i. 

2. VEGETABLE TONICS. 

Unless otherwise specified the doses are as follows : 

Extractum dose gr. iii. to gr. x. 

Decocturn } ~- ~ 2 .. 

Infusum / " 3 5 • o 

Tincturae „ 3$s. — 3II. 

47. Anthemidis extractum, infusum. 

48. Aurantii infusum, infusum compositum, syrupus, tinctura. 

49. Berberia? sulphas — dose. gr. i. to x. 

50. Calumbae extractum, infusum, tinctura. 

51. Cascarilla? infusum, tinctura. 

52. Chirata? infusum, tinctura. 

53. Cinchona? flava? extractum liquidum (dose 55s. to 3iss.}, decoctum, 

infusum, tinctura. 

54. Cinchona? (pallida?; tinctura composita. 

55. Cusparia? infusum. 

56. Gentiana? extractum, infusum compositum, tinctura. 

57. Lupuli extractum, infusum, tinctura. 

58. Nucis vomicae extractum (dose gr. J to gr. ii.), tinctura (VT\x. to 

TY\xx.). 

59. Pareira? extractum ; extractum liquidum ^dose 3ss. to 3iss.) ; de- 

coctum. 

60. Quassia? extractum, infusum. 

61. Quinia? sulphas (dose gr. i. to gr. v.) tinctura composita (dose 31. 

to 3iv.) vinum (dose 3ss. to 3J.) 

62. Serpentaria?, infusum, tinctura. 

63. Strychnia (dose gr. Jg to gr. -i). 

64. Strychnia? liquor (TYIy. gr. = ^) dose TYLiii. to TYl x. 



Tonics in the form of Draught. 



132. R. Quinia? disulphatis gr. ii. 

Tinctura? aurantii 3J. 
Infusi rosa? acidi Jiss. M. 

133. R. Liquoris arsenicalis TYIy. 

Infusi lupuli Jiss, M. 

134. R. Acidi nitrici diluti TY^xv. 

Infusi anthemidis Jiss. M. 

135. R. Infusi aurantii Jss. 

Tra?. Serpentaria? 3ss. M. 



136. R. Berberia? sulphatis gr. v. 

Infusi chirata? 3iss. 

137. R. Infusi calumba? Jiss. 

Acidi nitro-hydrochlorici 
diluti TTLxv. M. 

138. R. Soda? bicaibonatis gr. xx. 

Tinctura? cascarilla? 3J. 
Infusi calumba? ^hs. M. 



TONICS. 



671 



139. R. Infusi cuspariae Jiss. 

Liq. Stiychnise X)\iv m M. 

140. R. Infusi cascarillas §j. 

Tincturae aurantii 5J« M. 

141. R. Infusi lupuli Jiss. 

Tinctorae nucis vomicae 
TY\x. M. 

142. R. Dec. cinchona? flavse Jiss. 

Acid sulphurici dil. TY^xx. 
M. 

143. R. Infusi lupuli Jiss. 

Extr. pareiras liquidi 5J. 
Acidi hydrochloiici diluti 
rr^x. M. 

144. R. Trae. ferri perchloridi 

TT\xv. 
Infusi quassia? Jiss. M. 

145. R. Ferri et quiniae citratis 

gr. v. 
Syrupi aurantii floris 5J. 
Aqua: cinnamomi ^iss. M. 



146. R. Ferri tartarati gr. v. 

Infusi quassia? Jiss. M. 

147. R. Ferri et ammonise citratis 

gr. x. 
Spiritus ammonias arom. 

5ss. 
Aq. menthae pip. ^iss. M. 

148. R. Ferri iodidi gr. v. 

Spiritus myristicae 5ss. 
Aquae menth. puleg. ^iss. 

149. R. Ferri sulphatis gr. iii. 

Magnesia? sulphatis 3ss. 
Acidi sulphurici dil. 3ss. 
Aq. menth. pip. Jiss. M. 

150. R. Acidi phosphorici dil. Jij. 

Syrupi aurantii ^j. 
Aquae f 5xix. M. (To be 

used as a common 

drink.) 



Tonics in the form of Pills, 

151. R. Cupri sulphatis gr. J. 

Pilulae saponis co. gr. ii. 
Micas panis gr. ii. ft. pil. 

152. R. Zinci valerianatis gr. ii. 

Extracti lupuli gr. iii. 
M. Fiat pilula. 

153. R. Ferri sulphatis exsiccatae 

gr. v. 
Extracti anthemidis gr. v. 
Fiant pilulae duse. 



154. R. Quiniae disulphatis gr. j. 
Extracti gentianae gr. iv. 

M. 

155. R. Argenti oxidi gr. i. 
Extr. gentianae gr. iv. M. 

156. R. Argenti nitratis gr. J. 
Extr. hyoscyami gr.iv. M. 

157. R. Bismuthi subnit. gr. x. 
Conf. rosae gal. q.s. ft. pil.ii. 



Tonics in the form of Powder. 



158. R. Fern redacti gr. iii. 

Pulvis cinnam. co. gr. v. 
Mix for a powder. 

159. R. Ferri carbonatis saccha- 

ratae gr. x. 
Pulveris cinnam. co. gr. v. 
Mix for a powder. 



160. R. Ferri phosphatis gr. iii. 

Pulveris cinnam. co. gr. v L 
Mix for a powder. 

161. R. Ferri oxidi magnetici 

gr. iii. 
Pulvis cinnam. co. gr. v. 
Mix for a powder. 



( 672 ) 



10 



1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 
10. 
11, 
12. 

13. 
14. 
15. 

16. 
17. 
18. 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 
27. 
28. 
29. 



9. ASTRINGENTS. 

(a.) Mineral. 
The mineral acids 

Alumen dose gr. x. to gr. c. 

Alumen exsiccatum „ gr. v. — gr. xv. 

Argenti nitras „ gr. J — gr. i. 

Cadmii iodidi, et unguentum (used ex- 
ternally). 

Misturae cretas „ §L — 5& 

Cupri sulphas \ 

Ferri perchloridi, liquor et tinctura I c ^ . „„_ 

r .. .. V * > „ See Tonics, p. 6b 9. 

„ pernitratis liquor . j " ' ^ 

„ sulphas exsiccata, et granulate J 

Plumbi acetas „ gr. i. — gr. v. 

Zinci acetas, sulphas „ gr. ii. — gr. v. 

(6.) Vegetable. 

Belae extractum liquidura .... dose gi. — gii. 

Catechu, pallidum ,, gr. x. — gr. xxx. 

„ pulvis compositus „ gr. v. — gr. xxx. 

„ tinctura ,, 5 SS « — 3 n « 

„ infusum ,, Ji. — ^ii. 

„ trochisci „ ii. — xx. 

Cinchona pallida ,, gr.xxx. — gr. c. 

Cinchonas tinctura composite ,, ^ss. — 3ii. 

Granati radicis decoctum .... » ,?• — Jii. 

Hamotoxyli decoctum ,, ^i. — ^ii. 

Hsematoxyli extractum „ gr. x. — 35s. 

Kino pulvis compositus (1 err. opium in) 

r x l v > „ gr. v. — gr, xx. 

gr. xx.) J & 

Kino tinctura „ 3ss. — gii. 

Krameriae extractum ,, gr. v. — x. 

Krameriae infusum ,, ^iss. — ^ii. 

Krameriae tinctura „ ^ss. — ^ii. 

Kreasotum ,, n\i. — Tr\iii. 

Kreasoti mistura „ J, — ^ii. 

Maticas infusum „ ^ss. — Jiv. 

Pterocarpi lignum. 

Lavendulae tinctura composite . . . „ 3ss. — gii, 

Quercus decoctum „ ^i. — Jii. 

Gallae pulvis „ gr. x. — 3 ss. 

Gallas tinctura „ 3 ss. — 3 ii. 

Acidi tannici trochisci ,, ii. — xx. 

Acidi tannici suppositoria .... „ gr. x. — gr. xxx. 

Acidum gallicum, et tannicum ... „ gr. i. — gr. v. 

Acidi gallici et tannici glycyrinum . „ TY^x. — TY^xxx. 

Rosas (Gallicae) infusum acidum . „ ^i. — Jii. 



ASTRINGENTS. 



373 



30. 
31. 
32. 
33. 
34. 



Rosas (Gallicas) confectio dose 3ss. to 3ii. 

Rosas (Gallicas) syrupus ,, 3ss. — 311. 

Rosas caninas confectio „ 3ss. — gii. 

Ulmi decoctum „ f Jii, — f ^iv. 

Uvas ursi, infusum „ f ^i. — 3ii. 

(c.) Mineral and Vegetable. 

Pilula plumbi cum opio dose gr. ii. to gr. viii. 

Pulvis cretas aromaticus ,, gr. x. — gr. xxx. 

Pulvis cretas aromaticus cum opio . . ,, gr. x. — gr. xx. 

Astringents in the form of Mixture or Draught. 



162. 
163. 

(To 
164. 

165. 
166. 

167. 

175. 
176. 

177 



R. Aluminis gr. x. 
Syrupi 3J. 
Infusi rosas acidi Jiss. M. 

R. Acidi sulph. diluti f ^ss. 

Infusi rosi acidi f t ^vi. 

Syrupi rhasados f jii. 

Aquas destillatas f ^xii. 
be used as a common drink.) 

R. Acidi nitro-hydrochlorici 
diluti TT\xv. 
Tincturas kino 3i. 
Infusi uvas ursi Jiss. M. 

R. Misturas cretas Jj. 

Syrupi papaveris 3j. M. 

R. Pulvis cinnam. co. gr. xx, 
Tincturas opii VC\y. 
Misturas cretas ^iss. M. 

R. Tree ferri perchloridi 3ss. 
Infusi quassias ^iss. M. 



168. R. Liquoris ferri pernitratis 

TY\xv. 
Syrupi aurantii floris 3J. 
Aquas Jss. M. 

169. R. Extracti belas liquidi 3j. 

Infusi cusparias Jiss. M. 

170. R. Tincturas cinchonas com- 

posite 3j. 

Infusi uvas ursi Jiss. M. 

171. R. Tras. lavandulas compo- 

site 3j. 
Infusi kramerias ^iss. M. 

172. R. Syrupi rosas Gallicas 3j. 

Infusi catechu ^iss. M. 

173. R. Acidi gallici gr. v. 

Tincturas opii TT^v. 
Infusi rosas acidi Jiss. M. 

174. R. Tincturas kramerias 3j. 

Decoct, hasmatoxyli ^iss. 
M. 



Astringents in the form of Pill. 



R. Pilulas plumbi cum opii 
gr. iii.— gr. v. 



R. Acidi gallici gr. iii. 
Plumbi acetatis gr. i. 
Conf. rosas Gal. q. s. 
flat pil. 



ut 



R. Acidi gallici gr. iiss. 
Morphias gr. T 'g. 
Confectionis rosas Gallicas 



quantum sufficit ut ft. 
pil. 

178. R. Plumbi acetatis gr. i. 

Pilulas saponis compositas 
gr. ii. fiat pilula. 



179. R. Zinci sulphatis gr. ii. 
Pulvis opii gr. J. 
Extracti rhei gr. iii. 
Fiat pil. 

See also Formulas, p. 671. 

2 X 



674 



ASTRINGENTS. 



Astringents in the form of Powder. 

180. R. Pulv. cinchonas pallid. 1 181. R, Pulvis cretae aromatici 

gr. xl. cum opio gr, x. 

Acidi gallici gr. ii. Pulv. catechu comp. gr. x. 

Misce. et fiat pulvis. M. 



Astringent Lotions. 



182. R. Argenti nitratis gr. ii.-xl. 

Aquae destillatae Ji. Solve. 

183. R. Liquoris calcis Ji. 

Olei olivae ^ii. M. 

184. R. Cupri sulphatis gr. i ii.-xl. 

Aquae camphorae ^i. S. 

185. R. Acidi tannici gr. x, 

Acidi hydrochlorici dil. 

3ss. 
Aquae Ji. Solve. 

186. R, Liquoris plumbi subace- 

tatis Tr\xx. 



Glycyrini 3L 

Aquae rosae 3vii. Misce. 

187. R. Liq, plumbi subacet. 3ss. 

Spiritus rectificati TT\xxx. 
Aquae destillatae 3vii. 

188. R. Zinci chloridi gr. i. 

Aquae Ji. Solve. 

189. R. Zinci sulphatis gr. v. 

Tincturae lavendulae com- 

positae TY\xxx. 
Aquas Ji. Solve. 

190. R. Zinci sulphatis gr. i. to x. 

Aquae rosae ^i. Solve. 



Astringent Injections. 



191. R. Aluminis gr. c. 

Decocti queicus Oi. S. 

192. R. Cupri sulphatis gr. ii. — v. 

Aquae Ji S. et fiat in- 
jectio. 

193. R. Liq. ferri perchloridi Tr\iii. 

Aquae ^i. M. et fit. injectio. 



194. R. Liq. plumb, subacet. TY^x. 

Extracti opii liquidi ^ss. 
Aquae destillatae ^i. M. 

195. R. Zinci sulphatis 

Aluminis ana gr. ii. 
Aquae ^i. Solve. 



Astringent Colly ria. 



196. R. Aluminis gr. iii. to gr. x. 

Aquae ^i. Solve. 

197. R. Argenti nitratis gr. i. — v. 

Aquae destillatae f Ji. 

198. R. Cupri sulphatis gr. i. — v. 

Aquae Ji. Fiat collyrium. 



199. R. Hydrargyri perchlor. gr. 2 V 

Aquae ^i. S. Ft. collyrium. 

200. $. Plumbi acetatis gr. ii. 

Aquae destillate ^i. S. 

201. R. Zinci sulphatis gr. i. — v. 

Vini opii §i. 

Aquae 3 vii. Fiat colly- 
rium. 



DEPBESSENTS. 



675 



Astringent 

202. R. Aluminis 31. 

Acidi sulphurici arom^ss 
Tincturas myrrhas 3H. 
Decocti cinchonas Jvi. M. 



Gargles, 

203. R. Acidi tannici gr. c. 

Spiritus rectificati Jss. 
Aquas camphorse Jvss. M. 



Astringent Ointments. 
204. R. Argenti nitratis gr. xx. 
Adipis §i. M. Fiat un 
guentum. 



205. R. Acidi sulphurici 3SS. 

Adipis §i. Ft.unguentum. 

206. R. Cretas precipitatae §i. 

Olei olivas 51. 
Adipis Jss. Misce. 



207. R. Capri sulphatis gr. xxx. 
Adipis Ji. M. 



208. R. Hydrargyri perchlor.gr. y. 

Adipis Ji. M. 

209. R. Liq. plumbi subacet. 3J. 

Adipis Ji. Misce. 



10. DEPRESSENTS. 

1. Acidum hydrocyanicum dilutum . . . dose TY\ii. to n\viii. 

2. Antimonii oxidum „ gr. i. — gr. v. 

3. Antimonium sulpburatum . . . . „ gr. i. — gr. v. 

4. Antimonium tartaratum . . . . . „ gr. \ — gr. j. 

5. Antimoniale vinum (gr. i. in §ss.) . . ,, 55s. — 3H. 

6. Antimonialis pulvis (i gr. terox. in iii grs.) „ gr.iii. — gr. xv. 

7. Colchici seminis tinctura „ TY|xx. — gi. 

8. Colchici extractum „ gr. i. — gr. iii. 

9. Colchici extractum aceticum „ gr. i, — gr. iii. 

10. Colchici vinum ,, TY\xx. — 3ii. 

11. Digitalis infusum „ 3H. — 3iv. 

12. Digitalis tinctura ,, Tr\x. — 3SS. 

13. Digitalinum „ gr.^j — ^. 

14. Ipecacuanhas pulvis . . . . . . „ gr. v — gr. x. 

15. Ipecacuanhas vinum „ TY|xv. — 31. 

16. Lobelias tinctura „ TY]xx, — 31. 

17. Lobelias tinctura astheiea ,, TY^xx. — 31. 

1 8. Scillas syrupus „ 3L — 3H. 

19. Scillas tinctura „ jss. — 3i. 

20. Tabaci enema ,, Jiv. — J^iii- 

21. Veratri viridis pulvis „ gr. i. — gr. iii. 

22. Yeratri viridis tinctura ,, TY\v. — n\xx. 

It must be borne in mind that these are depressent doses. 



Depressents in the form of Draught or Mixture. 

210. R. Vini antimonialis 3ss. I 211. R. Vini colchici 3j. 

Aquas destillatas Jss. M. | Aquas campboras ^U 



U. 



676 



EMETICS— DIAPHORETICS. 



212. R. Tr. veratri viridis tt\rv. 

Aquas anethi ^iss. M. 



214. R. Acid. hydrocyanici dil.nqv. 
Misturse amygdalae Jiss.M. 



213. R. Tincturas digitalis TY\xv. 215. R. Vim ipecacuanhas TY\xv. 
Aquae cimiamomi Jiss. M. Aquae cinnamomi Jss. M. 

Depressents in the form of Pov:der. 



216. R. Antimouii tartarati gr. i. 

Sacchari albi gr. xxxi. M. 

(Divide into parts proportioned to 

the age, and give one, three, or 

four times a day.) 



217. R. Antimonii tartarati gr. i. 
Hydrargyri c. creta gr. xii. 
Sacchari albi gi. Misce, et 
in pulveris octo divide, 
sumat unamquaitishoris. 



11. EMETICS. 

There are two classes of emetics; the one consisting of stimulants, 
the other of depressents. A certain dose of either class of substances 
will excite vomiting. The following formulae comprise medicines of 
both classes : — 



218. R. Vini antimonialis Jss. 

219. R. Yini ipecacuanhas Jss. 

220. R. Pulvis ipecacuanhas gr. xx. 

Vini antimonialis ^>s. 
Aquas menthas piperitas 
5x. M. fiat haustus. 

221. R. Zinci sulph. gr. xx. to xl. 

Aquas cinnamomi Jss. M. 

222. R. Cupri sulphatis gr. x. 

Aquas ^iss. Ft. h. 

223. R. Sinapis pulvis ^ss. 

Aquas §iv. 
(In cases of poisoning.) 



224. R. Ammonias carbonatis. 

Pulvis ipecacuanhas gr. xx. 
Tincturas capsici 5ii. 
Aquas menthas piperitas 
f$i.M. 
(\\ hen the sensibility of the 
stomach is impaired,, as in poi- 
soning with opium.) 

225. R. Tabaci foliorum ^i. 

Aquas tepidas q. s. 
Bruise the leaves and apply the 
poultice to the epigastrium. 
(Must be removed as soon as 
sickness takes place v 



12. DIAPHORETICS. 

There are also two classes of diaphoretics ; the one consisting of 
stimulants, the other of depressents. Both classes are comprised in 
the following formulas :— 

Diaphoretics in the form of Draught. 

226. R. Liquoris ammonias acetatis I 227. R. Potassas nitratis gr. xx. 
giii. A'ini antimonialis 3ss. 

Aquae camphoras 5iss. M. Liq. ammonias acet. Jii. 

Ao. menthas pip. ^iss. M. 



EXPECTORANTS. 



228. R. Ammonias carbonatis gr. x. 

Spiritus chloroformi 3J. 
Aquas Jiss. M. 

229. R. Spiritus astheris nitrosi 3L 

Liq. ammonias acet. 3ii. 
Syrupi hemidesmi 3J. 
Aq. Jiss. M. 



230. R Potassas nitratis 3SS. 

Tincturas opii TY\xv. 
Mist, amygd. Jiss. M. 

231. R. Tras. guaiaci ammon. 3JSS. 

Tincturas opii XX\y. 
Aquas pimentas Jiss. M. 



Diaphoretics in the form of Poicders. 



232. R, Pulvis ipecacuanhas gr. x. 

233. R. Pulv. ipecacuanhas co.gr.x. 
Antimonii tartarati, snr- 1. M. 



234. R. Pulvis ipecacuanhas gr. i. 
Pulvis antimonialis gr. x. 
Sacchari gr. vi. M. 



13. EXPECTORANTS. 



There are also two classes of expectorants; the one stimulant, 
the other depressent. Expectorants of both classes are to be found in 
the following preparations and formulas : — 

1. Acidum benzoicum dose gr. v. to gr. xxx. 

2. Ammoniacum „ gr. v. — gr. c. 

3. Ammoniaci mistura „ Jss. — J ss * 

4. Antimonium tartaratum ,, gr. ^ — gr. J. 

5. Balsamum Peruvianum 

6. Balsamum tolutanum 

7. Benzoinum 

8. Benzoini composita tinctura (Friar's balsam) 

9. Galbanum 

10. Ipecacuanhas pulvis 

1 1 . Ipecacuanhas vinum 

12. Ipecacuanhas pulvis composita .... 

13. Lobelia inflata 

14. Lobelias tinctura „ TT(x. 

15. Lobelias astherea tinctura . . . . 

16. Scillas pilula composita ..... 

17. Scillas syrupus 

18. Scillas tinctura 

19. Senegas infusum 

20. Senegas tinctura 

21. Tinctura tolutana 

22. Vinum antimoniale 

Expectorants in the form of Draughts. 



3 1 - 


— 3 11 - 


3 1 - 


— 3". 


gr. xx 


.— gr. 1. 


3ss e 


— 3*. 


gr. x. 


— gr. I. 


gr. 1. 


■ — gr. v. 


Vr\x. 


- 3ss. 


gr. 11. 


— gr. v. 


gr. 1. 


— gr. v. 


TTlX. 


— 3ss. 


TY\X. 


— 3ss. 


gr. v. 


— gr. x. 


3 1 - 


— 3". 


TY\X. 


— ^ss. 


#> 


- Ss- 


#- 


— 3". 


TTtxX. 


— TV^xl. 


3 ss. 


— 3 ! - 



235. R. Ammon. carbonatis gr. v. 

Spiritus chloroformi 3ss. 
M. 



236. R. Balsami Peruviani 3SS. 
Glycyrini * 3j. 
Mist, amygdalae Jjss. M. 
* This is commonly but wrongly spelt " Glycerine." 



678 



DEMULCENTS. 



237. R. Ammonias carbonatis. 

Ammou. benzoatis a gr.v. 
Yini ipecacuanhas TY^x. 
Decocti senegas ^iss. M. 

238. R. Vini ipecacuanhas TY^x. 

Syrupi papaveris 3J. 
Spiritiis amnion, arom. 

3ss. 
Aquae camphoras Jiss. M. 

2 39. R. Syrupi scillas f 3ss. 

Misturas ammoniaci £iss. 
M. 

240. R. Balsami copaibas 5ss. 
Vitelli ovi 5J. 
Aquas cinnamomi ^iss. 
Fiat emulsio. 



241. R. Liquoris ammonias aceta- 

lis 3iii. 
Syrupi scillas gi. 
Decocti senegas 3J. M. 

242. R. Tras. lobelias asthereas 3SS. 

Tincturas sci.llas 3ss. 
Aquas camphoras §jss. M. 

243. R. Vini antimonialis TY\xl. 

Liquoris ammon. acet. 3U 
Oxymellis scillas 3J. 
Aquas pimentas §i. M. 

244. R. Vini ipecacuanhas TT\xl. 

Potassas bicarbonatis 

gr. xx. 
Aquas ^iss. M. (to be taken 

with a table-spoonful of 

lemon- juice.) 



Expectorants in the form of Pills. 



245. R. Pilulas scillas co. gr. v. 

Fiat pilula. 

246. R. Pil. ipecacuanhas cum. 

scilla gr. v. Fiat pil. 

247. R. Antimonii tartarati gr. \. 



Pulv. ipecacuanhas co. 

gr. viii. 
Mucilagicis acacias gr. ii. 
Fiant pilulas duas. 

248. R. Pilulas scillas compositas. 
Extracti conii aa gr. v. 
Fiant pilulas duas. 



DEMULCENTS. 

1. Acacias gummi. Mucilago Acacias. 

2. Amygdalas (dulces). Pulvis amygdalas compositus. Mistura amyg- 

dalas. Oleum amygdalas. Oleum olivas. Cetaceum. Manna. 
Lac. 

3. Amyli mucilago. 

4. Decoctum hordei, cetrarias, ulmi. 

5. Glycyrrhizas radix. Pulvis glycyrrhizas. Extractum glycyrrhizas. 

6. Glycyrinum. 

7. Lini semen. Infusum lini. 

8. Mel. 

9. Rosas caninas confectio. 

10. Syrupus floris aurantii, hemidesmi, mori, rhasados, tolutanus. 

11. Tragacantha. Mucilago tragacanthas. Pulvis tragacanthas compo- 

situs. 



DEMULCENTS — EMOLLIENTS — LAXATIVES, ETC. 



679 



Demulcents in the form of Draught. 



249. R. Cetacei gr. c. 

Vitelli ovi 3J. 
Syrupi tolutani. 
Aquae cinnam. a 5J. 
Aquae Q. M. 

250. R. Mannse optimae gr. c. 

Infnsi lini Oii. M. 

251. R. Mucilaginis tragacanthae. 

Lactis vaccini ana Ibi. 
Sacchari h. M. 



252. R. Syrupi hemidesmi ^ii. 

Decocti hordei Jxviii. M. 

253. R. Decocti cetr arise ^xviii. 

Syrupi mori Jii. M. 

254. R* Decocti ulmi ^xviii. 

Confec. rosae caninse ^ii. 
M. 

255. R. Misturae amygdalae §xvi. 

Glycyrini Jiv. Mix. 



15. EMOLLIENTS. 



1. Decoctum papaveris. 

2. Cataplasma lini, fermenti. 

3. Glycyrinum. 

4. Oleum amygdalae, lini, olivae. 

5. Unguentum cetacei, simplicis. 



6. Cera alba. 

7. Sapo, linimentum saponis, lini- 

mentum calcis, emplastrum 
saponis. 



10. 
11. 
12. 

13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 
21. 
22. 



6. LAXATIVES, APERIENTS, CATHARTICS, ENEMATA. 

Aloe. Barbadensis dose gr. v. to gr. x. 

„ Decoctum aloes compositum . . ,, Jss. — Jii. 

„ Enema ,, ^x. — |xx. 

,, Extractum „ gr. v. — ■ gr. x. 

„ Extractum. Barb, et Socot. . . ,, gr. v. — gr. x. 

„ Pilula „ gr. v. — gr. x. 

„ Socotrina „ gr. y. — gr. x. 

„ Tinctura aloes ,, 3J. — J. 

„ Vinum aloes „ ^ii. — 3vi. 

Amygdalae oleum „ Ji. — v ^ii. 

Cambogia „ gr. ii. — gr. v. 

Colocynthis. Extractum colocynthidis com-} 

positum ! 

Pilula colocynthidis composita . . • f " 
Pilula colocynthidis et hyoscyami . . ) 

Crotonis oleum „ Vf\), — TY\iii. 

Elaterium ,, gr. -^ — gr. i. 

Extractum colocynthidis compositum . . ,, gr. v. — gr. x. 

Fel bovinum purificatum ,, gr. v. — gr. x. 

Fici pulpa „ Iss. — Ji. 

Hydrargyrum: Calomelas . . . . . „ -gr. i — gr. x. 

Hydrargyrum cum creta „ gr. i. — gr. v. 

Jalapae pulvis „ gr. v. — gr. xx. 



630 



APERIENTS. 



23. 

24. 
25. 

26. 
27. 
28. 
29. 
30. 
31. 
32. 
33. 
34. 
35. 
36. 
37. 
38. 
39. 
40. 
41. 
42. 
43. 
44. 
45. 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59. 
60. 

61. 

62. 
63. 
64. 
65. 
66. 
67. 
68. 



levis 



Jalapas Extractum 

„ Pulvis compositus (gr. v. in gr 

„ Pulvis scammonii compositus 
(about gr. v. in gr. xv.) 

„ Resina . 

„ Tinctnra 
Magnesia, et magnesia levis 
Magnesias carbonas, et carbonas 
Magnesias earbonatis liquor 
Magnesias sulphas . 
Magnesias sulphatis enema . 
Manna . . 

Pilula aloes et assafoetida . 
Pilula aloes et myrrhae . 
Pilula calomelanos composita 
Pilula cambogia composita . 
Pilula hydrargyri . 
Pilula rhei composita . 
Podophylli pulvis . 
Podophylli resina . 
Potassae sulphas 
Potassse tartras 
Potasses tartras acida . 
Pruni pulpa .... 
Rhamni succus .... 
Rhamni syrupns 
Rhei extractum .... 
Rhei infusum .... 
Rhei pilula composita . 
Rhei pulvis ..... 
Rhei pulvis compositus . 
Rhei syrupns .... 
Rhei tinctura .... 
Pacini oleum .... 
Scammoniae radios pulvis . 
Scammoniae resina . 
Scammonii confectio 



mistura 

pulvis compositus 
gr. viii.) 

- Extractum coiocynthidis compO' 

si turn 
~ Mlula colocynthidi; 

- Pilula coiocynthidis 



Scammomum 

Senna, Alexandiina, et Indica. 

Sennas confectio 

Sennas infusum .... 

Sennas syrup us .... 



; composita 
et hyoscyami 



dose t 



, v. to 
. xv. — 



gr. x. 
gr. 1. 



gr. 
3 j - 

gr. 

gr. 



V. — err. x. 



1. — 



gr.i 
gr. i 
gr. \ 
gr. i 

gr.^ 
gr. . 

gr. 1 

3". 

3ss. 

5J- 

gr. j 

s. 

gr. 

g r - 
g r - 
3i- 

3 ii. 

3^ 

gr. 
gr- 

gr. 



gr. 


1. 


$L 




gr- 


X. 


gr« 


X. 


gr. 


X. 


gr. 


X. 


gr. 


X. 


gr. 


X. 


gr. 


XX, 


gr. 


1. 


gr. 


cc 


gr. 
9- 


c. 


33- 





v. 


— 


gr. 


X. 


XV 


— 


gr. 


1. 


XXX 


gr. 


cc 






^h 






— 


£ 






— 


s- 




X. 


- — 


gr. 


XX 


X. 


— 


gr. 


V. 


XX 


— 


ffr. 


1. 




— 


^ 





gr. x. — gr. xx. 



}•• 



gr. v. — gr. x. 



gr. v. — 



gr. x. 
gr.x. 



gr. v. — gr. x. 



gr. 1. 



3J- - 



ccc. 
3*- 



APERIENTS. 



681 



Sennas tinctura dose 3J. to 5iv. 



70. Sodas et potassas tar tras . 

71. Sodas sulphas 

72. Sodii chloridum 

73. Sulphur, precipitatum et sublimatum 

74. Terebinthinas enema .... 

75. Terebinthinas oleum .... 



gr. c. — 5ss. 
gr.cc.— 5j. 
gr. c. — Iss. 

z 
gr. cc. — 5ss. 

Jss. — gii. 



Laxatives, Aperients, Cathartics, in the form of Draught. 

263. R, Tmcturaecanlamomi com- 
posites 3±i. 



256. R. Potassas tartratis gr. c. 

Decocti aloes comp. f §ss. 
M. 

257. R. Olei amygdala? Jii. 

Olei cinnamomi TY\i. 

Vitelli ovi unius. 

Sacchari albi gr. c 

Muclig. acacias Jiss. 
M. fiat emulsion. 
(One half for a dose.) 

258. R. Olei crotonis Tr\i. 

Olei ricini f Ji. Ft, h. 

259. R. Magnesiae sulphatisgr.ee. 

Mannas gr. 1. 

iDfusi sennas Jiss. Ft. h. 

260. R. Pulvis rhei gr. x. 

Potassas tartratis Jss. 
Infusi sennas ^iss. 
Tincturae sennas gii. Ft. b. 

261. R. Sodas et potassae-tart. ^ss. 

Magnesiae gr. x. 
Aq.menthas pip.Jiss. Ft.h. 

262. R. Magnesias carbonatis gr. x. 

Magnesias sulphatis gr. 1. 
Tincturae zingiberis TY\xv. 
Aquas menthas piperita? 
Jiss. Fiat haustus. 



Magnesia carbonatis gr. x. 
Infusi rhei Jiss. Ft. h. 

264. R. Infusi rosas acidi §iss. 

Magnesiae sulphatis gr. c. 
Syrupi rosas 5J. M. 

: 265. R. Potassas tartratis gr. c. 
Mannas gr. lx. 
Aquae pimentae Jiss. 

I 266. R. Olei ricini. 

Olei terebinthinae. 
Mucil. acacias aa Jss. M. 

267. R. Tincturae sennas 31L 

Yini aloes 5U. 
Syrupi zingiberis 5L 
Aq. menthas pip. |iss, M. 

268. R. Radicis armoracias con- 

tuses Jii. 
Seminis sinapis. 
Radicis Valeriana? aa gr. c. 
Radicis rhei incisas 3ss. 
(Infuse in Oiss. of port wine. A 
wine-glassful as a warm ape- 
rient.) 

269. R. Olei ricini Jss. 

Vitelli ovi unius. 

Aq. menthas viridis Jj. 

Syr. aurantii Jj. M. 



Laxatives, Aperients, Cathartics, in the form of Pills. 



270. R. Aloes extracti Barbadensis. 

Pulvis zingiberisaa gr.iiss. 

Extracti anthemidis gr. v. 
Fiant pilulas duas. 

271. R. Extracti aloes Socotrinas. 

Saponis duri a gr. v. Ft.p.ii. 



272. R. Pil. aloes et myrrhas gr. vi. 

Pulvis capsici gr. ii. Ft. 
p. ii. 

273. R. Extr. colocynthidis comp. 

Extr. gentianas a gr. iiss. 
Fiat pilula. 



682 



APERIENTS — ENEMATA. 



274. R. Calomelanos gr. i. 

Pil. coloc. et hyos. gr. viii. 
Olei anethi TY\i. 
In pilulas duas divide. 

275. R. Extr. colocynth. comp. 

Calomelanos aa gr. v. 
Fiant pil. duas. 

276. R. Resinas scammonias. 

Calomelanos. 
Ext. colocynthidis comp. 
Extracti jalapae a gr. ijss. 
Olei carai quantum suf. 
Fiant pilulas duas. 

277. R. Ext. colocynthidis comp. 

Resinas jalapae. 



Gambogias ana gr. iiss. 
Resinae podophylli gr. J 
Olei juniperi q.s. 
Fiant pilulae duae. 

278. R. Olei crotonis TY^i. 

Pulvis aloes q.s. M. Ft. 
pil. 

279. R. Resinae podophylli gr. ss. 

Extr. anthemidis gr. viii. 
Fiant pilulae duae. 

280. R. Pilulae hydrargyri gr. iii. 

Extracti colocynthidis 
compositi gr. vii. M, 
Ft. pil. ii. 






Laxatives, fyc, in the form of Powder. 



281. R. Pulvis jalapae comp. gr. 

xl. Fiat pulvis. 

282. R. Pulv. rhei comp. 5J. Ft. p. 

283. R. Pulvis rhei gr.xx. 

Potassae bitartratis gr. 1. 
Pulvis aromatici gr. v. M. 



284. R. Pulvis rhei gr. x. 

Calomelanos gr. iii. 
Pulveris aromatici gr. v. 
M. 

285. R. Pulv. scammonias co.gr.x. 

Calomelanos gr. v. M. 



Laxatives, ( 

286. R. Confectio sulphuris gr. c. 
Pulveris cinnam. co. gr. 
xx. M. 



, the form of Electuary. 

287. R. Confec. scammonii gr.xxx. 
Resinae podophylli gr. J.M. 



PURGATIVE ENEMATA. 



1 . Enema aloes. 

2. Enema magnesias sulphatis. 

288. R. Infusi anthemidis f Jx. 

Sodas sulphatis ^i. M. 

289. R. Extcolocynthidis co.gr.xl. 

Infusi sennas Jxii. M. 

290. R. Ext. aloes Socotrinas gr.xl. 

Lactis communis fjvi. M. 



3. Enema terebinth inas. 

4. Enema assafostidas. 

291. R. Decocti hordei ^x. 

Ovi vitelli unius. 

Olei ricini ^i. Ft. enema. 

292. R. Sodii chloridi Ji. 

Decocti hordei Oi. M. 
Fiat enema. 



( " 683 ) 





17. 


DIURETICS. 






(a.) Saline. 






1. 


Ammonias acetatis liquor . 


dose 3ii. 


to 3vj. 


2. 


Ammonias benzoas 






» gT- x - 


— gr. xx. 


3. 


Lithise carbonas 








„ gr. iii. 


— gr. viii. 


4. 


Lithias citras . 








» gr- v. 


— gr. xv. 


5. 


Potassas carbonas . 








» gr. x. 


— gr. xxx 


6, 


Potassas acetas 








„ gr. x. 


Z }g r - »• 


7. 


Potassas bicarbonas 








. „ gr. x. 


8. 


Potassas chloras 








„ gr. x. 


— gr. xx. 


9. 


Potassas citras . • 








„ gr. xxx. 


— gr. 1. 


10, 


Potassas liquor 








„ TYtxv. 


— TT\k. 


11. 


Potassae nitras . 








„ gr. x. 


- gr. 1. 


12. 


Potassas tartras acida 








„ gr. xxx. 


— gr. c. 


13. 


Potassae tartras 








„ gr. xxx. 


— gr. c. 


14. 


Sodas liquor 








» TTIXV. 


— Tr\l. 


15. 


Sodas acetas 








„ gr. xxx. 


— gr. c. 


16. 


Sodas bicarbonas . 








„ gr. x. 


— gr. 1- 


17. 


Sodas citro-tartras effervescens 


„ gr. lx. 


— gr. cc. 


18. 


Sodas et potassas tartras (Startaratf 
(6.) Vegetable 


i) „ gr. c. 


— gr. ccl. 


19. 


iEtheris nitrosi spiritus . 


dose 5ss 


— 3ii. 


20. 


Armoracias spiritus compositus 


5 > 3J- 


— 3ii. 


21. 


Buchu infusum 


„ f^ 


-.f£i. 


22. 


Buchu tinctura 


„ ^ss. 


— 3U- 


23. 


Copaiba 


„ rr^xx. 


— 3ss. 


24. 


Copaibas oleum 


„ lYliii. 


— nq,xx. 


25. 


Cubebas pulvis 


„ gr. xx. 


— gr. 1. 


26. 


Cubebas oleum 


„ ir|iii. 


— TY\xx. 


27. 


Digitalinum ...... 


» gr-A 


— o-r -L 

o * 30* 


28. 


Digitalis pulvis 


»f gr- i 


— gr. iss. 


29. 


Digitalis infusum 


» 3"- 


— 3iv. 


30. 


Digitalis tinctura . 


„ Trxx. 


— TT^xxx. 


31. 


Juniperi oleum 


», TYtiv. 


— TYlvi. 


32. 


Juniperi spiritus 


„ ^iss. 


— 3J- 


33. 


Pareiras decoctum .... 


» s- 


— $>. 


34, 


„ extractum liquid um . 


„ 3ss. 


— 3"- 


35. 


Sabinas pulvis 


„ gr. iv. 


— gr. x. 


36. 


Sabinas oleum 


» TYti. 


— TY\ui. 


37. 


Sabinas tinctura . 


„ Trixx. 


— 3i. 


38. 


Sapo durus et mollis 


„ gr- x. 


— gr. xx. 


39. 


Scillas pulvis 


„ gr. v. 


— gr. xx. 


40. 


Scillas syrupus 


» 3 j . 


— 3 1 * 1 - 


41. 


Scillas tinctura 








„ XT[xy. 


— 5*- 



684 



1 DIUEETICS 






42. Scillse pilula composita . 


. dose gr. v. 


to gr. x. 


43. Scoparii succus 






„ 3ss. 


— 3'j- 


44. Senega? decoctum 






■ » 9. 


-Si- 


45. Taraxaci decoctum 






„ £ 


-S«. 


46. Taraxaci extractum . 






„ gr. x. 


— gr. xsx 


47. Taraxaci succus . 






■ » 3 1 *- 


— 31V. 


48. Terebinthina Canadensis 






» gr. x. 


— gr. xl. 


49. Terebinthinae oleum . 






„ 3 SS - 


~ 3"- 


50. Terebinthinse confectio 






,, s;r. lx. 


— gr. cl. 


51. Uvae ursi infusum 






n fc 


- J". 



(c.) Animal. 
Cantharidis tinctura .... dose TY\v. — TY\xx. 



Diuretics in the form of Draujht, §c. 



293. R. Ammoniae benzoatis gr. x. \ 299 
Ext. pareirae liquid! 3J. 
Decocti pareirae Jiss. M. 



294. R. Lithire citratis gr. x. 

Acidi citrici gr. xx. 

Syrupi aurantii ^ss. 

Aquas f ^ii. Solve. 
To be taken in a state of effer- 
vescence with gr. xiv. bicarbonate 
of soda dissolved in f Jii. water. 

295. R. Potassae nitratis gr. xv. 

Potassae bicarbonatis 

gr. xxx. 
Spiritus juniperi 3ss. 
Infusi buchu 31SS. M. 

298. R. Potassae nitratis Jss. 
Dissolve in a quart of lemonade 
for a common drink. 

297. R. Potassae acetatis gr. xl. 

Infusi digitalis 3ii. 
Sp. aetheris nitrosi 3J. 
Decocti taraxaci Jiss.ft. H. 

298. R. Potassae tartratisacidae^ss. 

Corticis limonis, et sac- 

chari q.s. 
Aquae ferventis Oii. 
(For a common drink.) 



R. Sodae et potas. tart. gr. lx. 
Spiritus juniperi 3J. 
Succi scoparii 3SS. 
Decocti taraxaci ^iss. M. 

R. Copaibae 3SS. 
Vitelli ovi. q. s. 
Sacchari 3J. 

Aquae menthae virid. Jiss. 
M. fiat emulsio. 

R. Infusi buchu Jiss. 

Spiritus juniperi c. 3i. 

R. Taraxaci succi. 

Spiritus juniperi ana 3J. 
Tincturae scillse 3SS. 
Decocti scoparii Jiss. M. 

R. Sabinae tincturae 3SS. 
Infusi buchu Jiss. M. 

304. R. Acidi nitrici diluti Tr\x. 

Tinct. hyoscyami 3SS. M. 
Decocti pareirae ^iss. 

305. R. Tincturae cantharidis TT\x. 

Spiritus juniperi 3J. 
Decocti pareirae ^iss. M. 

306. R. Trae. seminis colchici 3ss. 

Potassae acetatis gr. lx. 
Aquae foeniculi ^i ss . M. 



300. 

301. 
302. 

303. 



DIURETICS — ANTHELMINTICS. 



685 



Diuretics in the form 

307. R, Pilulas seillae compositae 

gr. x. 
Calomelanos gr. J. 
Olei juniperi TY\j, 
Fiant pilulse duae. 

308. R. Pulvis digitalis gr. i.— ii. 

Hydrargyri pilulas gr. ii. 
Pilulas scillas co. gr. vi. 
M. Et in pilulas ii. divide. 

309. R. Digitalini gr. 4 

Pubis scillse. 
Extracti taraxaci ana gr. y. 
Misce et ft. pil. ii. 

310. R. Potassae nitratis gr. x. 



of Pill, Powder, §c. 

Potassas tart, acidse gr. xx. 
Fiat pulvis. 

311. R. Olei cubebse TY^xx. 

Saponis duri gr. x. 
Pulvis glyeyrrh. q. s. ut 
fiant boli duo. 

312. R. Terebinthinae Canadensis 

gr. v. 
Olei cubebae, TY\,i. 
Pulvis glycyrrhizae, q. s. 

flat bolus. 

313. R. Extracti taraxaci Jss. 

Pulvis scillas gr. xl. 
Confec. terebinthinae Jss. 
Succi taraxaci, q, s. fiat 
electuarium. 



18. ANTHELMINTICS. 
Preparations of the London Pharmacopoeia. 



Calcis liquor (as an enema) 
Cusso infusum 
Filicis extractum liquidum 
Filicis maris pulvis 
Granati corticis decoctum 
Granati corticis pulvis 

Kamela 

Mucuna pruriens {non-officinal) 
Pulvis scammonii compositus 
Quassias infusum (as an enema) 

Santoninum 

Spigelian Marylandicas radicis pulvis 

{non-officinal) . 
Terebinthinae oleum . 



dose 



&■ 

gr. xx. 

gr. xx. 
gr. xxx. 
gr. xx. 
gr. y. 

I*. 



^ss. 



to 



- Jviii. 

■ 3iii. 

• gr. c. 

- gr. c. 

- gr. c. 

- gr. xx. 
-IW. 

- gr. vi. 

■ gr- c. 



314. R. Olei terebinthinae Ji. 

Decocti hordei Ji. M. ft.h. 

315. R. Mucunae prurientis gr. c. 

Theriacas Ji. M. 
(A tea-spoonful for a dose.) 

316. R. Extracti filicis liquidi ji. 



Pulv. tragacanthse comp. 

gr. 1. 
Aq. menthse piperitae ^ii. 
Fiat haustus. 



317. R. Santonini gr. ii. 
Pulv. scammonii 
gr. viii. 
Fiat pulvis. 



comp. 



686 



EMMENAGOGUBS — ANTACIDS — ANTISEPTICS, ETC. 



19. EMMENAGOGUES. 

1. Rutae oleum dose TY\ii. to TY^v. 

2. Sabinae oleum „ TY^i. — TY^v. 

3. Sabinas tincturas „ TT^x. — 3L 

For the other remedies of this class, see Tonics, especially those con- 
taining steel, myrrh, and aloes. 



318. R. Ferri et ammon. cit. gr. x. 

Tincturas sabinae rn_xx. 
Aqua cinnamomi Jss. M. 

319. R. Olei rutae TY^iv. 

Pulveris myrrhae gr. iv. 



Pulvis aloes gr. ii. 
Fiant pilulae duae. 

320. R. Olei sabinae Thjv. 

Pulvis myrrhae gr. v. 
Saponis mollis q. s. 
Fiant pilulae duae. 



20. ANTACIDS. 



1. Ammonias liquor, acetas, carbonas, benzoas, phosphas. 

2. Ammonias spiritus aromaticus. 

3. Guaiaci tinctura ammoniata. 

4. Valerianae tinctura ammoniata. 

5. Calcis liquor, liquor saccharatus ; calx carbonas precipitata ; 

„ ,, chlorinata; creta preparata. 

6. mistura cretas. 

7. pulvis cretas aromaticus. 

8. pulvis cretas aromaticus cum opio. 

9. Lithiae, carbonas, citras. 

10. Potassas liquor ; acetas; carbonas; bicarbonas ; citras; tartras ; 

tartras acida. 

11. Sodas liquor; carbonas; carbonas exsiccata ; bicarbonas; sodas et 

potassas tartras ; citro-tartras effervescens. 

12. Magnesia; magnesia levis ; magnesias carbonas ; carbonas levis. 

13. Pulvis rhei compositus. 

14. Sapo mollis, durus. 

(For Formulae, see Diuretics, &c.) 



21. ANTISEPTICS AND DISINFECTANTS. 

1. Acidum aceticum. 

2. Acidium carbolicium, dose gr. i. to gr. iii. 

3. ,, „ glycyrinum gr. iv. — gr. xii. 

4. Carbo. 

5. Carbo animalis. 

6. Cataplasma carbonis, fermenti, sodas chlorinatas. 



ALTERATIVES. 



687 



7. Kreasottim. 

8. Liquor calcis chlorinatae. 

9. Liquor chlorinii. 

10. Liquor sodae chlorinatae. 

11. Pix liquida. 

12. Potassae permanganatis liquor. 

13. Zinci chloridum. 



22. ALTERATIVES. 

1. Acidum nitro-hydrochloricum dilutum ; acidum arseniosum (dose 

50 to -i gr.) ; liquor arsenicalis (dose. TY\ii. to TT^x.) ; liquor 
arsenici hydrochloricus (dose |TY\ii. — TY\yiii.) ; liquor sodas 
arseniatis (dose TY\v. to TY\x.). 

2. Antimonium sulphuratum ; antimonium tartaratum ; vinum an- 

timoniale (gr. \ in gi.) ; antimonii oxidum (dose gr. i. to gr. v.) ; 
pulvis antimonialis gr. v. to gr. x. 

3. Brominium (dose J to gr. ii.). Potassii bromidi (dose gr. iii. to 

gr. xxx.). 

4. Dulcamaras infusum ^j. — Jii. 

5. Ferri arsenias (dose gr. ^ — gr. J). 

6. Ferri iodidum (gr. i. to gr. x.) ; syrupus ferri iodidi (gr. ivss. in 

3L) ; pilula ferri iodidi (dose gr. v. to gr. x.). 

7. Hemidesmi syrupus 3J. 

8. Hydrargyrum cum creta (dose gr. iii. to gr. viii.) ; H. perchlo- 

ridum (dose gr. -jL to gr. J). 

9. Hydrargyri iodidum rubrum (dose gr. *g to gr. J) ; — iodidum viride 

(dose gr. i. to gr. iii.) ; — oxidum rubrum ; pilula ; linimentum ; 
unguentum ; unguentum hydrargyri ammoniati ; unguentum 
hydrargyri iodidi rubri ; unguentum hydrargyri nitratis ; un- 
guentum hydrargyri oxidi rubri ; hydrargyri emplastrum ; 
emplastrum ammoniaci cum hydrargyro. Calomelas (dose 
gr. \ to gr. ii.), pilula calomelanos composita, unguentum 
calomelanos. 

10. Iodinii ; tinctura (dose TY\v. to TY\xxx.) ; linimentum ; unguentum 

compositum, linimentum. 

11. Potassii iodidi (gr. i. to gr. x.) ; emplastrum ; unguentum; unguen- 

tum iodinii compositum ; tinctura iodinii ; linimentum iodinii. 

12. Morrhuae oleum. 

13. Sarsas decoctum ; decoctum compositum ; extractum liquidum. 

Alteratives in the form of Draught. 



321. R, Liq. hydrarg. perchloridi 

Tincturae chloroformi co. 

3ss. 
Aquae menthse pip. Jiss. M. 



322. R, Potassii iodidi gr, v. 

Inf usi aurantii Jiss. Ft. h. 

323. R. Syrupi ferri iodidi 3J. 

Decocti sarsae co. £iss. 
Ft. h. 



688 



ALTERATIVES. 



324. R. Potassii bromidi gr. x. 

Infusi dulcamarse £iss. 
Fiat h. 



325. R. Dec. sarsaa comp. ^iss. 

Acidi nitrici hydrochlo- 
rici diluti TY^x. Ft. h. 

326. R. Liquoris arsenicalis TY^v. 



Tinct. chlorof. co. Tt\xx. 
Infusi aurantii Jiss. Ft. h. 

327. R. Liq. sodse arseniatis TT^v. 

Sodae bicarbonatis gr. lx. 
Aq. pimentse Jiss. Ft. h. 

328. R. Liq.arsenicihydrochlorici 

TT\iii. 

Syrupi hemidesemi 3J. 
Aquae anethi Jiss. Ft. h. 



Alteratives in the form of Pill. 



329. R. Calomelanos gr. iii. 

Pil. saponis comp. gr.xviii. 
Ft. pil. xii. One every two, 
three, or four hours. 



330. R. Hydrarg. iodidi rubri gr. i. 
Extracti sarsae 5J. 
Fiant pil. xii. (One for a 
dose.) 



Alteratives in the form of Pousder. 

Fiant pulveres decern. (One 
for a dose.) 

333. R. Hydrarg. c. creta gr. i. 
Sacchari albi gr. v. 

Fiat pulvis. 

334. R. Ferri arseniatis gr. i. 
Pulvis cinnam. co. gr. lx. 

Fiant pulv. decern. (One 
for a dose.) 



331. R. Hydrarg. c. creta gr. xx. 

Antimonii tartarati gr. i. 
Sacchari gr. lx. 
Fiant pulveres decern. (One 
for a dose.) 

332. R. Calomelanos gr. iii. 

Pulvis opii gr. i. 

Pulvis glycyrrhizas gr. lx. 



Alteratives in the form of Bath. 

335. R. Potassii sulphidi £x. 
Aqua? callidae ex. 
Fiat balneum. 



( 689 ) 



GLOSSAEIAL INDEX. 



Abscess. (Abscessus, us, in. fr. abscedo, to escape), 65. 

Acne. Pimple (dx^V, scurf), 631. 

jEgophony. (ai£, a goat, (pcavh, the voice), 160. 

Amblyopia, cb, f. Impaired vision (a^SAus, weak, &ty, the eye), 600. 

Amaurosis, is,f. Blindness (a.fj.avpbs, obscure), 603. 

Amenorrhoea, ce,f. {a, priv., fx^v, a month, peca, to flow), 563. 

Anaemia, cb, f. Want of blood (a, priv., aifia, blood), 258. 

Anaesthesia, cb, f. (a, priv., cfio'drio'is, sensation), 389. 

Anasarca, cb, f. {ava, through, <rhp^, the flesh), 270. 

Aneurism, {avevpvvoo, to dilate), 440. 

Angina, cb, f. Choking (crypto, to throttle), 423. 

Anorexia, cs,f. (a, not, ope^is, an appetite), want of appetite, 191. 

Anuria, ce,f. Suppression of urine (a, priv., ovpea), to pass urine), 

555. 
Aphonia, cb, f. Loss of voice (a, priv., (pcovr], sound), 449. 
Aphtha, cb, f. Thrush (a<pQa, fr. airro), to inflame,, 486. 
Apnoea, cb, f. Breathlessness (a, priv., irvea), to breathe), 32. 
Apoplexia, cb, f. (airoTrXTj^ia, fr. airoirX-qcrcroo, to strike down), 374. 
Arachnitis, idis,f. (apdx v ''h a spider's web, and itis), 370, 381. 
Ascaris, idis, f. (aaicapU, fr. &orKapi£oo, to jump;, 645. 
Ascites, cb, in. Dropsy of the belly (cur/ar^s, fr. acr/cbs, a sack), 526. 
Asphyxia. Apparent death (a, priv., <T<pv£i.s, the pulse), 32. 
Asthenia, (a, priv., (rOeuos, strength), 31, 290. 
Asthma, atis, ii. (acfyici, fr. aad/j.d(cc, to gasp), 460. 
Astigmatism, Astigmatismus, i, m. (fr. a, not, crriy/jLa, a spot), 604. 
Atavism. Atavismus, i, m. (atavus, a grandfather), 4. 
Atheroma, atis, n. A morbid deposit [addprj, porridge), 439. 
Atrophy. Wasting (a, priv., rpocpy, nourishment), 82, 431. 

Bronchitis, idis, f. (fip6y%os, the windpipe, itis), 456. 
Bronchocele, es,f. ($p6yxos, the windpipe, ktjXtj, a tumour), 495. 
Bulimia, cb, f. (/8o£, excess, Xl/jlos, hunger), 35. 

Cachexia, cb, f. Bad habit of body (KaKrj, bad, e£is, habit), 261. 
Calculus i, m. (Lat. calculus, a little stone), 535, 551. 
Cancer, cri, m. and n. A malignant disease {cancer, a crab), 504, 570. 
Carcinoma, atis, n. Cancer (jtapKivos, a crab), 87. 

2 Y 



690 GLOSSARIAL INDEX. 

Carditis, id is, f. (/capSta, the heart, and itis\ 431. 

Catalepsy, Catalepsis. {Kard\r)\pis, eccs, tj, fr. KaraXajx^oLVca, to 
seize), 405. 

Catamenia, orum, pi. n. (Kara, according to, fxr)v, the month), 563. 

Catarrhns, I, rn. A cold ( Kara, down, peco, to flow), 454. 

Cephalalgia, a?,f. Headache f K€<pa\r), the head, &\yos, pain), 361. 

Cheloidea, a?,/. A cutaneous disease (x^Aus, a tortoise, eldos, like- 
ness), 639. 

Chloasma, atis, n. (xXodfa, to be green), 613. 

Chlorosis, is, /. Green sickness (xAcopbs, green), 260. 

Cholera, cb, /. (x°^> b^ e - P ew > t0 flow), 520. 

Chorea, #,/. (x°P €La i a dancing), 406. 

Choroiditis, idis.f. (xopiov, skin, elSos, likeness, and lifts), 594. 

Chronic, Chronicus, a, urn. r xP° U0S > time), 20. 

Clonic, Clonicus, a, um. {x^ovos, commotion), 100. 

Colica, cb, f. kooXov, the colon y , 516. 

Coma, atis, n. Complete loss of sensation and voluntary motion, 
(KufjLa, aros, to, deep sleep), 206, 392. 

Congestion. Fulness of blood ' congestio, fr. congero, to heap up), 269. 

Corneitis, idis, f., and Cornea, CB,f. (cornu, a horn, it is), 590. 

Cyanosis, is, f. Blue disease (kvclvos, blue), 437. 

Cystitis, idis, f. {kvctls, a bladder, it is), 560. 

Delirium, i, n. Wandering (d.eliro, to rave), 115. 

Dermmycosis, is, /., a contraction for dermato-mycosis. (fr. Sep/ma, 

aros, to, the true skin, fxvKrjs, a fungus), 616. 
Diabetes, is, m. (did, through, fiaiva, to pass), 556. 
Diarrhoea, cb, f. (Blol, through, pew, to flow), 512. 
Diphtheria, cb, f. (dicpOepoa), to cover with skin), 325, 
Dropsy. (u5pa>i|/, fr. vficop, water) 270. 
Dysentery, Dysenteria, cb, f. (pvs, with difficulty, eurepou, the 

bowels), 509. 
Dysmenorrhea, cb, f. (Bbs, difficult, /jlt)j/, sl month, pew, to flow), 565. 
Dyspepsia, cb, f. {§vs, difficult, ireirTca, to concoct), 500. 
Dysphonia, cb, f. (5us, difficult, (pwvr], voice), 494. 
Dyspnoea, cb, f. (§vs, with difficulty, izvloo, to breathe), 186. 
Dysuria, cb, f. (pus, with difficulty, oupeco, to pass urine), 562. 

Ecthyma, atis, n. Cutaneous pustules (eKOvw, to break out), 630. 
Eczema, atis, n. Running scab (e/c£e'o>, to boil up), 624. 
Electrode, (jiksnrpov, amber, o56s, a way), 394. 
Elephantiasis, is, f. (ikecpavTLao-is, fr. i\€<pas, an elephant), 637. 
Embolism, Emholismus, i, m. \ fr. iufiaWw, to drive in), 442. 
Emphysema, atis, n. (ifxcpvGrijjLa, fr. ifxcpvcrdoo, to inflated, 464. 
Emprosthotonos, adj. (e/jLTrpoaOev, forwards, reiucc, to bend), bent 

forwards, 410. 
Empyema, atis, n. Pus (eV, within, ttvov, pus), 482, 
Emunctory, Envmctorium, i, n. (fr. emungo, to carry off), 70. 
Encephalitis, idis,f. (eV, in, KecbaXr], head, itis), 364. 



GLOSSABIAL IXDEX, 691 

Endemic. Indigenous (eV, among, Btjiios, a people; or, eV, in, druuos. 

a district), 296, 553, 559. 
Endocarditis, idis, f. (evBov, within, KtxpSla, the heart, it is), 430. 
Enteritis, Mis, /. (eurepou, the bowels, itis), 508. 
Entozoa, pi., Entozoon, i, n. (evros. within, (ojoz/, an animal), 643. 
Enuresis, is,f. Incontinence of urine (eV, in, ovpeco, to pass urine), 561. 
Ephelis, idis,f. Freckles (e<pr\\\s, fr. iirl and 7]Aios, the sun), 640. 
Epidermmycosis, is, /., contraction for epidermato-mycosis. (fr. e7rt- 

d€p/u.ls, the cuticle, /llvktjs, a fungus), 613. 
Epidemic. Prevalent (iirl, among, dri/j.os, a people), 455. 
Epilepsy. Falling sickness (iiriXri^ia ; iiriXa/jL^duco, to seize upon), 

402. 
Equinia, ce, f. Glanders (equus, a horse), 341. 

Erysipelas, atis, n. (ipv&iireAas, fr. ipvcc, to draw, Tr4\as, near), 273. 
Erythema, atis, n. Inflammatory blush (ipvdaivco, to redden), 621. 
Exanthemata, pi., Exanthema, atis, n. (ij-av04a>, to break out into 

red spots), 307. 

Febricula, ce, f. (dim. offebris), 265. 
Febris, is, f. (ferveo, to be hot,) 277. 
Frambcesia, ce, /. The yaws (framboise, Fr., a raspberry), 638. 

Gangraena, ce, f, (ydyypaiva, fr. ypdco, to eat), 66. 

Gastralgia, ce,f. Pain in the stomach (yaffTTip, the stomach, aXyos, 

pain), 499. 
Gastritis, idis,f. (yaffr^p, the stomach, itis), 499. 
Gastrodynia. (yacrriip, the stomach, ohvvt), pain, itis), 501. 
Gastro-enteritis, idis,f. (ya(TT7}p, the stomach, zvrepov, the bowels, 

itis), 519. 
Gingivitis, idis,f. {gingivae, the gums, #zs), 491. 
Glaucoma, atis, n. (fr. ^Aav/cbs, sea-green), 602. 
Glossitis, idis,f. (yKaxrva, the tongue, itis), 491. 
Gonorrhoea, ce, f. (70Z/77, seed, peeo, to flow), 577. 

Haematemesis, is, f. {cujia, blood, e^uetns, vomiting), 498. 
Hematuria, ce, f. Bloodv urine (af^ua, blood, ovpeco, to void urine,, 

552. 
Haemoptysis, is, f. Spitting of blood (af/^a, blood, tttixtis, spitting), 

471. 
Haemorrhage. Bleeding (atfia, blood, priyvvixi, to burst forth), 270. 
Haemorrhois, idis, f. (aTfia, blood, peca, to flow), 518. 
Hectic. A remittent fever (1/cTt/cbs, habitual), 331. 
Hemiplegia, ce, f. Palsy of one side (Juxicrvs, half, TrX-qcraco, to strike), 

390. 
Hepatitis, idis,f. (v,irap, rjiraros, the liver, itis), 529. 
Herpes, etis, m. Tetter (cpira>, to creep), 626. 
Homologous, (ofibs, like, \6yos, condition), 85. 
Hydatid, (vdarls, idos, t), a small bladder, fr. vdoop), 438, 540. 
Hydrocephalus, i, m. (yhwp, water, KecpaXr], head), 371. 



692 GLOSSARIAL INDEX. 

Hvdropericardiurn, i, n. (wSeop, water, tt€o\, around, KapSia, the 

heart), 429. 
Hydrophobia, cc.f. Canine madness (vdccp, water, (pofios, fear), 413. 
Hydrops, opts, m. (fr. vdoop, water), 270. 
Hydrorachis, eos, f. (vScap, water, pdx LS > * ne spine), 380. 
Hydrothorax, dcis, f. (vbccp, water, 6d>pa£, the chest), 482. 
Hypersernia. (uxep, excess, aXfxa, blood ; , 256. 
Hyperesthesia, (virep, excess, aXaQ-qcris, sensation), 101. 
Hypertrophy, (virep, over, rpocpv), nourishment), 81. 
Hypnotic, hj/pnoticus, a, m. {v-kvos, sleep, sleep inducing), 248. 
Hypochondriasis, is, m. Low spirits (vwb, under, x^^pos, cartilage), 

418. 
Hysteralgia, ce,f. (ixrripa, the womb, uXyos, pain), 386 
Hysteria, 05,/. Hysterics {vcrrepa, the womb), 387, 407. 
Hysteritis, idis, f. (vffrepa, the womb, itis), 338, 568. 

Icterus, i, m. Jaundice CiKT€pos, a yellow bird), 536. 
Idiosyncrasy (t^Los, peculiar, avv, with, Kpacris, temperament), 6. 
Ichthyosis, is,f. Fish-skin (IxOva, the scale of a fish), 637. 
Impetigo, inis, f. Running tetter (Lat. impetigo, fr. impeto, to assail), 

638. 
Inflammation. (Lat. inflammatio, fr. in and flamma), 266. 
Influenza, a?, /. Epidemic catarrh (fr. influo, to abound), 455. 
Intus-snsceptio, dais. f. (intus, within, and susceptio, a taking), 515. 
Iritis, idis,f. (iris, a rainbow, itis), 591. 
Ischuria, <z,f. Suppression of urine (Icrxovpia, fr. fC%6u, to restrain, 

ovpov, urine), 555. 
Itis. ('ltj/jll, to urge against, thus denoting violent action, and used as 

a termiual to indicate inflammation), 22. 

Kyestein. (Kvyoris, ecos, r), pregnancy, iordrjs, fjros, r), a covering), 134. 

Laryngismus, i, m. (\dpvyyi£a>, to vociferate), 453. 

Laryngitis, idis,f. {\dpvy£, the larynx, itis), 446. 

Lepra. A cutaneous disease f XeTTpbs^ scaly), 637. 

Leucocvthemia, ce. f. (XevKos, white, kvtos, & cell, and al]ua, blood), 
262. 

Leucorrhcea, CB,f. The whites (\evnbs, white, peco, to flow), 566. 

Lichen, enis, n. A cutaneous disease (AetxV? a lichen), 633. 

Lumbago, inis, f. (lumbus, the loins), 357. 

Lumbricus, i, m. (Ascaris lumbricoides) round worm (lubricus, slip- 
pery), 643. 

Lupus, i, m. (lupus, a wolf), 640. 




XllCIrtUOUUiiaj W>, J • ^^M.C/x.w.H' wv, uiai,A, ^Lf/W/, U11CI, J.J.U, 41 I. 

Melasna, ce,f. Haemorrhage from the bowels (fjL€\aiva, black), 497. 
Melanosis, is, /. A morbid product of a black colour (fieXas, /xeXavos, 
black), 87. 



GLOSSAKIAL INDEX. 693 

Melasma, at is, n. (fr. fxeXas, black), 263. 

Meningitis, idis, f. (fxr\vLy^, a membrane, itis), 370. 

Menorrhagia, ce.f. flooding {/jliiv, a month, prjyuvfjLL, to break forth), 

565. 
Mentagra, cb, f. (mentum, the chin, 'dypa, seizure), 616. 
Metritis, idis, /. Inflammation of the womb (^rpa, the womb, itis) , 

338, 568. 
Miliaria, a?, f. Miliary fever (milium, a millet seed), 627. 
Mimosis, is, f. (fxifAos, a mimic), 264. 
Mollities, ei, f. (Softening, fr. mollis, soft), 348. 
Molluscum, i, n. (molluscum, the bunch of the tree acer), 639. 
Myelitis, idis, f. Inflammation of the spinal cord (fxveXos, marrow, 

itis), 380. 

Narcotic, narcoticus, a, m. (yapxoo), to stupify), 243, 248. 
Nephritis, idis,f. (ye<ppbs, the kidney, itis), 543. 
Neuralgia, cb, f. (yevpov, a nerve, &Xyos, pain), 385. 
Nosersesthesia. Morbid sensation (yocr-qpbs, unhealthy, cuc-OrjcrLS, 
sensation), 101. 

(Edema, atis, n. (oldea), to swell), 270. 

Oesophagitis, idis, f. (ofooo, to carry, (bay (a, to eat, itis), 496. 

Oophoritis, Oophorum, i, n., an ovary (oibv, an egg, cpepw, to bear, 
itis), 575. 

Ophthalmia, cb, f. Inflammation of the eye (bcpBaXfxbs, the eye), 585. 

Opisthotonos adj. (oiriade, at the back, reivoo, to bend), bent back- 
wards, 410. 

Osteo-malacia, cs,f. (ocrreov, a bone, paXaKia, softness), 348. 

Otitis, idis,f. (uvs, oorbs, the ear, itis), 605. 

Palpitatio, onis,f. (palpito, to throb), 421. 

Paracentesis, is, f. Tapping (irapa, through, Kei/rea), to pierce), 375. 

Paralysis, is,f. Palsy (irapaXvca, to relax), 390. 

Paraplegia, ce,f. Palsy of the lower half of the body (jrapa7rX7}(T(Tcc, 

to strike), 392, 441. 
Parotitis, idis, f. (irapa, near, oorbs, of the ear), 494. 
Pellagra, cb, f. (pellis agria, wild skin ; or (peXXbs, the bark of the 

cork-tree, and ay pws, wild), 636. 
Pemphigus, i, m. (jretjicpiyos, of a small blister), 628. 
Pericarditis, idis,f. (irepl, around, KapSia, the heart, itis), 426. 
Peritonitis, idis, f. (nepiTovaiov, fr. irepl, around, tzlvoj, to extend, 

itis), 524. 
Pertussis, is, f. Whooping-cough (pertussis, a continual cough), 465. 
Pestis, is,f. The plague (Lat. pestis), 328. 
Petechise, a, ce,f. (petechio, a flea bite), small purple spots, 349. 
Phlebitis, idis, f. Inflammation of the veins ((pXety, (/>Ae/3bs, a vein), 

443. 
Phlegmasia, cb, f. {(pXeyfxa, a burning, fr. cpXeyoo, to burn), 445. 
Phlegmon. Phlegnwne, es,f. (fr. cpXtyoo, to burn), 40. 



694 GLOSSARIAL INDEX. 

Phlogosis, is, f. ((pXoyoxris, a burning, <p\oyooo, to inflame), 266. 

Phrenitis, idis,f. (<pp7]v, (ppevbs, the mind, itis), 364. 

Phthisis, 2.s./. Consumption (<pQicris, fr. (pdico, to consume), 473. 

Pityriasis, is, f. Dandiirf {Trirvpov, bran , 611. 

Plethora. Fulness of blood (irXrjOwpa, fulness), 256. 

Pleuritis, idis, /. Inflammation of the pleura (irXevpa, the side), 480. 

Pleurodyne. (TrXevpa, the side, bhvvf], pain), 356. 

Pleurosthotonos, adj. (irXevpoQev, from one side, reivu), to bend), 

bent sideways, 410. 
Pneumonia, ce,f. Inflammation of the substance of the lungs (ttvev- 

fiw, the lung), 468. 
Pneumothorax, dels, /. Air in the pleura (irvev/jia, air, dcopal-, the 

chest), 484. 
Podagra, ce,f. Gout (irodbs, of a foot, dypa, seizure), 357. 
Polyaemia, cb, f. (ttoXvs, much, cu/ma, blood), 256. 
Polypus, i, m. (ttoXvs, many, nobs, a foot), 571. 
Porrigo, mis, m. and/, (jporrum, a leak), 615. 
Prurigo, inis,f., Pruritus, (prurigo, itching, prurio, to itch), 634. 
Psora, (E,f. The itch (\j/dbpa), 610. 
Psoriasis, is,f. Dry scall (^copa, the itch), 635. 
Ptosis, is,/, (fr. tttoco, to fell), 398. 
Puerperal, (pucr, a boy, pario, to bring forth), 336. 
Purpura, ce, /. Scurvy (purpura, a shell-fish yielding a purple dye), 

349. 
Pyaemia, ce,f. (irvov, pus, aTjua, blood), 334, 497. 
Pyogenic, (pyogenicus, a, urn, fr. ttvov, pus, yeuvdec, to form), 334. 
Pyrexia, ce,f. Fever (irvpe^is, fr. irvp ; e%co, to hold), 266. 
Pyrosis, is, f. Water-brash (irvpcocns, burning), 506. 

Quinsy, {pynanche, fr. kvqov, a dog, &yx&> to strangle), 492. 

Piachitis, idis, f. Pickets (p&xis, the back), 346. 

Retinitis, idis, f. Inflammation of the retina (rete, a net and itis), 596. 

Rheumatism, Eheumatismus, i, m. (fr. pev/xa, a fluxion), 352, 

Rubeola, 65,/. Measles (rubeo, to be red), 316. 

Rupia, cb, f. A cutaneous disease (pviros, filth), 629. 

Scabies, ei, /. The itch (scabies, fr. scabo, to scratch), 610. 
Scarlatina, adj., us, a, urn. Febris understood, 319. 
Sciatica, cb, f. Pain in the hip (lo~XLas, fr. Xcrxi-ov, the hip),, 388. 
Sclerotitis, 'idis, f. ((TKXripbs, hard, and itis), 589. 
Scorbutus, i 9 m. Scurvy (Lat. scorbutus), 350. 
Scrofula, ce,f. King's evil (scrofula, a little pig), 4, 344,. 588. 
Scybala, plur., hard faeces. ((TKvfZaXov, ov, rb, dung), 515. 
Septicaemia, ce, f. (fr. arjira), to putrefy, oI/llcl, the blood), 334. 
Spermatorrhoea, cb, f. (enrepfxa, seed, pew, to flow), 583. 
Splenitis, idis, /. Inflammation of the spleen (o-kXt]v, the spleen, itis), 
542. 






GLOSSAEIAL IXDEX. 695 

Stomatitis, idis, f. Inflammation of the mouth (crrofxa, the mouth, 

itis), 485. 
Stridulus, a, um. Creaking, 453. 

Struma, pi. us, i, m . King's evil (ffrpoofxa, a heaping up), 4, 344. 
Sycosis, is, f. Chin-welk (gvhoco, to convert into a fig), 616. 
Syncope, es, f. Fainting ((TuyKOTTToo, to cut down), 424. 
Syphilis, idis, f. (fr. crvy, together, (piXioo, to love), 578. 

Tabes (is, /.) mesenteric^, (tabes, a consumption, fxeaevrepLov, the 

mesentery), 400, 525. 
Taenia, os,f. Tape-worm (tcenia, a riband, from reivou, to stretch). 

648. 
Tetanus, i, m. Locked jaw (reiuca, to stretch), 410. 
Thrombosis, is, f. (fr. 6p6/j.fios, a clot of blood), 442. 
Tic doloreux. (Fr. tic, a convulsive motion, doloreux, painful), 386. 
Tonic, tonicus, a, m. (fr. reivoo, to tighten), 241. 
Tonsillitis, idis,f. (tondeo, to clip? and itis), 492. 
Tormina, en, mis, n. (fr. torqueo, to rack), griping pains, 515. 
Tracheitis, idis,f. (rpaxe7a aprrjpia, rough artery, itis), 452. 
Trismus, i. m. Locked jaw (rpicr/Jibs, fr. rpi(co, to gnash the teeth), 

410. 
Tympanites, ce, m. Drum-belly (rv/jLiravoeLd^s, like a drum), 518. 
Typhoid, (typhus, and elSos, like), 296. 
Typhous, (typhosus, pertaining to typhus), 291. 
Typhus, i, m. (rvcpbs, fr. rvcpoa), to stupefy), 288. 

Urticaria, ce,f. Kettle-rash (urtica, a nettle), 622. 

Vaccina, ce, f. Cow-pox (vaccinus, belonging to a cow), 313. 
Varicella, ce, f. Chicken-pox (dim. of varus, a spot), 315. 
Variola, ce,f. Small-pox (dim. of varus, a spot), 307. 
Varioloid, (variola, small-pox, eidos, like), 580. 
Vibices, vihex, icis, (f. purple blotches of the skin), 295. 

Zymotic. Contagious and infectious diseases (fyfAcocris, fermentation, 
fr. CvfjLow, to ferment). An inappropriate term. 21. 



( 096 ) 



INDEX. 



Abdomen, dropsy of, 526 

, examination of, 139 

A chorion Schonleinii, 618 

Abscess, 65 

Absorption, physiology of, 72 

■, remedies which promote, 

73, 247 
JEgophony, 160 

as folliculorum, 611 

. scabiei, 610 

Acne, 631 

Age, its influence on disease, 6 

mortality, 7 

Ague, 2 IS 

Air, change of, 212 

— , impure, as a cause of disease, 15 

— , in the chest, 484 

Albumen, in urine, tests for, 134 

Alopecia, 615 

Alteratives, doses and formula?, 687 

Amaurosis, 603 

Amenorrhoea, 563 

Amentia, 116 

Amphoric resonance, 160 

■ respiration, 158 

Anaemia, 258 

, chronic, 259 

, 260 

Anaesthesia, 389 
Analogous formations, 82 
Anasarca, 270 
Aneurism of the aorta, 440 

heart, 437 

Angina pectoris, 423 
Animal heat, 101 

-Ties, and stimulants, formulae, 668 

, doses and formulae, 667 

Antacids, formulae, 686 
Anthelmintics, doses and formulae, 685 
Anthrax, treatment of, 64 
Antidotes for the poisons. 655 
Antiseptics and disinfectants, 227, 686 
Antispasmodics, 657 

, sedative, 668 

, stimulant and sedative, 

668 



Anuria, 555 

Aorta, aneurism of, 440 

Aperients, 235 

Aperients, doses and formulae, 

Aphonia, 449 

Aphthae, 486 

Apoplexy, 77, 374 

Appetite, the, 191 

Arachnitis, cerebral, 370 

Arcus senilis, 65 

Areolar tissue, dropsy of, 270 

Arteries, degeneration of, 439 

, functions of, 58 

, obliteration of, 438 

Ascaris lumbricoides, 643 
vermicularis, 645 



679 



Ascites, 526 

Astigmatism, 604 

Assimilation, primary and secondary, 42 

Asthma, 460 

Astringents, doses and formulae, 672 

Atheroma, 83, 439 

Atmospheric impurities, influence of, on 

health, 15 
pressure, its effect on the 

body, 13 
Atrophy, 82 

— of the bones, 348 

brain, 379 

heart, 431 

- liver, 530, 539 

retina, 59 



Auscultation of the abdomen, 143 

heart, 166, 427, 433 

lungs, 157 



Babracks, site and arrangement of, 222 
Bile, composition and use of, 39, 40, 52 

, in urine, tests of, 133 

Bilharzia haematobia, 554 
Biliary concretions, 535 
Bladder, inflammation of, 560 
Bleeding from the bladder, 552 
Bleeding from the bowels, 497, 513 
lungs, 471 



697 



Bleeding from the stomach, 498 

Blindness, 603 

Blood, cause of bufly coat in, 44 

, circulation of, 56 

, fulness of, 256 

, loss of, effects of, 258 

— — , physiology and pathology~of, 43 

, spitting of, 199, 471 

« , vomiting of, 498 

Blood-letting, 243 
Bloody flux, 409 
Bloody urine, 134, 552 
Blue disease, 437 
Boils, 64 

Bones, softening of, 348 
Bothriocephalus latus, 649 
Bowels, disorders of, 194, 508 

, invagination of, 515 

-, looseness of, 512 

, obstruction of, 514 

Brain, atrophy of, 379 

, circulation through, 76 

, diagnosis of diseases of, 368 

, functions of, 102 

— - — , hypertrophy of, 379 

, induration of, 379 

, inflammation of, 364 

, softening of, 378 

, water on, 37 1 

Breast pang, 423 
Breath, odour of, 192 
Bronchial respiration, 153 
Bronchitis, 456 
Bronchocele, 495 
Bronchophony, 160 
Bruit anaemic, 259 

de diable, 171 

de mouche, 171 

de rape, 168 

de scie, 163 

— — de soufflet, 168 
— — musculaire, 160 
Buffy coat in blood, cause of, 44 

Cachexia, 261 
Calculi, biliary, 535 

, urinary, 551 

Cancer, 87, 504, 541, 570 

Capillaries, fatty degeneration of, 440 

, functions of, 59 

, influence of nerves on, 61, 94 

, remedies on, 243 

, state of, in inflammation, 60 

Carbon, elimination of, 50, 53 
Carbonic acid gas, quantity expired, 49 
Carbuncle, 64 
Carcinoma, 87, 541, 570 

of the stomach, 504 

Carditis, 431 
Catalepsy, 405 
Catalytic medicines, 237 
Catarrhus — Catarrh, 454 
Catarrhus epidemicus, 455 



Cathartics, 235 



5 and formulae, 679 



Cell theory, i 
Cellulitis venenata, 340 
Cephalalgia, 361 
Cheek, gangrene of, 489 
Cheloidea, 639 
Chest, capacity of, 151 

, dropsy of, 482 

, examination of, 145 

, measurement of, 146 

Chicken-pox, 315 
Chionyphe Carteri, 620 
Chloasma, 613 

Chloroform, administration of, 425 
resuscitation from, 426 



Chlorosis, 260 
Cholera, English, 519 

malignant, 520 



Chordee, 578 

Chorea Sancti Viti, 406 

Choreic hemiplegia, 391 

Choroid, diseases of, 594, 598 

Cbyle in urine, 131, 559 

Chyme, 37 

Circulating system, physiology and 

pathology of, 56, 195, 421 
Circulation, cerebral, 76 

, influence of nerves on, 94 

, remedies which act on, 237 

, venous, 71 



Cirrhosis, 530 
Cleanliness, 212 
Clergyman's sore throat, 494 
Climate, its influence on health, 10 
•, change of, 212 



Clothing, 209 
Cold, action of, 242, 249 
Colica— Colic, 516 
Colica pictonum, 517 
Colitis, 509 
Coma, 392 
Condiments, 232 
Congestion, 68, 269 

-, cerebral, 76 



Conjunctiva, inflammation of, 585 

Constipation, 234, 514 

Consumption, 473 

Convulsions, 100, 205 

Cornea, inflammation of, 590 

Coughing, diagnosis by, 197 

Cough, whooping, 465 

Countenance, expression, in disease, 206 

Cow-pox, 313 

Crepitation, 159 

Cretinism, 117 

Croup, 452 

, spasmodic or false, 453 

Cutaneous diseases, 608 
Cyanosis, 437 
Cystine, 131 
Cystitis, 560 
Cystorrhcea, 560 



698 



Dastdriff, 636 
Deafness, 607 
Death by apnoea, 32 

asthenia, 31 

syncope, 32 

, causes of, 29 

Debility, state of the circulation in, 98 
Delirium, febrile, 115 

, tremens, 115, 419 

Delusions, 112, 119 
Dementia, 117 
Demulcents, formulae, 678 
Dengue, 283 
Dentition, painful, 491 
Deodorants, &c, 227 
Depressants, 241 

, doses and formulae, 675 

Dermmycosis circinata, 616 

favosa, 617 

■ sycosa, 616 

Diabetes, 556 

Diagnosis, 24 

Diaphoretics, doses and formulae, 676 

Diarrhoea, 194, 234, 512 

Diathesis, 3 

Dietaries, 222 

Digestion, 34 

Diphtheria, 325 

Disease, causes of, 22 

, classification of, 22, 255 

, diagnosis of, 24 

, forms of, 20 

, nomenclature of, 21 

, prognosis of, 25 

, symptoms and signs of, 23, 

122 

, terminations of, 20 

-, treatment of, 27 

Disinfectants, &c, 227, 686 

Dissection- wounds, 340 

Diuresis, 559 

Diuretics, doses and formulae, 683 

Doses, tables of, 657 et seq. 

Dracunculus, 612 

Drainage, 210 

Dreams, analysis of, 112 

Dropped hand, 399 

Dropsy, 270 

, encysted, 576 

, of the abdomen, 526 

- areolar tissue, 270 



chest, 483 

heart, 429 

, theory of, 74 

Drum-belly, 518 

Dwelling, the, as affecting health, 210 
Dysenteria — Dysentery, 509 
Dysmenorrhcea, 565 
Dyspepsia, 500 
Dysphonia clericorum, 494 
Dyspnoea, table of causes of, 186 
Dysuria, 562 



Ear, diseases of, 605 

Ecbinococcus in the heart, 438 

! ■ liver, 540 

I Ecthyma, 630 
I Eczema, 624 

Electricity, animal, 102 

. , atmospheric, 13 

remedial use of, 394 



Elephantiasis, 637 
Embolia and embolism, 442 
Emetics, 233 

, doses and formulae, 676 

Emollients, formulae, 679 
Emmenagogues, doses and formulae, 

686 
Emphysema, 464 
Empyema, 482 
Encephalitis, 364 
Endocarditis, 430 
Endosmose and Exosmose, 73 
Enteritis, 508 
Entozoa, 540, 553, 643, 650 
Enuresis, 561 
Epidermmycosis decalvans, 615 

tonsurans, 615 

versicolor, 613 



Ephemeral fever, 265 
Epidemic constitutions, 14 
Epilepsy, 402 
Epileptic hemiplegia, 391 
Epithelium scales in mine, 135 
Equinia, 341 
Eruptive fevers, 307 
Erysipelas, 67, 273 
Erythema, 621 
Exanthemata, 307 
Excito-motory system, 96 

-, pathology of, 97 



Excretions, the, 70 

Exercise, 208 

Exhaustion, treatment of, 240 

Expectoration, the, 198 

Expectorants, doses and formula?, 677 

Eye, diseases of, 585 

, normal appearance of, 593. 

Face, paralysis of, 396 
Faeces, the, 41 
Fainting, 240, 424 
Falling sickness, 402 
Famine lever, 303 
Farcmoma — Farcy, 341 
Fat in urine, 132 
Fatty degeneration, 83 

of the arteries, 84 

brain, 37! 



Favus, 617 

Febricula, 265 

Fever, cerebrospinal, 295 

, dandy, 283 



- cornea, 85 

- heart, 431 

- liver, 539 



699 



Fever, enteric, 296 

, ephemeral, 265 

■ , hectic, 331 

, inflammatory, 266 

, intermittent, 278 

, miliary, 627 

, milk, 339 

, puerperal, 336 

, pyogenic, 334 

, relapsing, 303 

, remittent, 282 

, infantile, 332 

, rheumatic, 352 

, scarlet, 319 

, typhoid, 296 

-, typhus, 288 

, vesicular, 628 

, yellow, 284 

Fevers, classification of, 277 

, eruptive, 307 

, general observations on, 277, 287 

, management of cases of, 254 

, prevention of contagion, 254 

Filaria medinensis, 612 
Food, classification of, 38 

, unwholesome, its effect on health, 

16 

, what kinds most digestible, 38 

Flooding, 565 
Formulas, 657 
Frambcesia, 638 
Fremitus, vocal, 160 
Fungus foot of India, 619 
Furunculus, 641 

Gall-stones, 535 
Gangrene, 66 

of the lungs, 471 

of the mouth, 439 

Gastralgia, 499 

Gastric juice, 37 

Gastritis, 499 

Gastrodynia, 501 

Gastro-enteritis mucosa, 519 

Genital organs, diseases of, 563 

Gingivitis, 491 

Glanders, 341 

Glands, structure of, 70 

Glaucoma, 602 

Gleet, 578 

Glossary, 689 

Glossitis, 491 

Goitre, 495 

Gonorrhoea, 577 

Gonorrhceal ophthalmia, 588 

Gout, 357 

Gravel, 550 

Green-sickness, 260 

Guinea- worm, 612 

Gums, diagnosis by, 190 

, inflammation of, 491 

Gutta serena, 603 



Habit, 105 

Habits, influence of, on health, 17, 

212 
Haematamesis, 498 
Hematuria, 134, 552 

, endemic, 553 

Haemoptysis, 199, 471 
Hemorrhage, 69, 270 

, from the bladder, 134, 552 

bowels, 513 

kidney, 134, 544 

lungs, 199, 471 

stomach, 498 

uterus, 5Q5etseq. 



, treatment of, 245 



Heemorrhcea petechial is, 349 

Haemorrhoids, 518 

Hay fever, 463 

Headache, 361 

Health, means of preserving, 208 

Health and disease, 1 

Hearing, sense of, 204 

Heart, action of, 56 

— — , atrophy of, 431 

, diagnosis of diseases of, 433 

, dilatation of, 437 

, diseases of, 421 

, dropsy of, 429 

, entozooic disease of, 438 

, examination of, 162 

, fatty degeneration of, 431 

, hypertrophy of, 436 

, impulse of, 167 

■-, inflammation of, 431 

— , movements of, 166 

, nervous palpitations of, 421 

, neuralgia of, 424 

, position of, 162, 165 

, rhythm of, 1 66 

, sounds of, abnormal, 433 

— normal, 167 



, spasm of, 424 

, valves of, their position, 164 

, valvular disease of, 427, 432 

Heat, animal, 101 
Hectic fever, 331 
Hemicrania, 362 
Hemiplegia, 390 

, spinal, 391 

Hepatitis, 529 

Hereditary predisposition, 3 

Herpes, 626 

, circinatus, 616 

, tondens, 615 

Heterologous formations, 85 

Hiccough, 197 

Hippuric acid, tests for, 128 

Hospitals, construction and arrangement 

of, 219 
Humming-top sound, 259 
Hunger and thirst, 35 
Hydatids, 438, 540 
Hydrocephalus, 371 



700 



Hydronephrosis, 549 
Hydropericardiuru, 429 
Hydrophobia, 413 
Hydrops — Dropsy, 270 
Hydrorachis, 380 
Hydrothorax, 482 
Hygiene, private, 208 

— , public, 216 

Hypertrophy, 81 

of the heart, 436 

Hypochondriasis, 118, 418 

Hysteria, 407 

Hysterical asthma, 387, 463 

hemiplegia, 391 

pain, 387 

Hysteritis, 338, 568 

ICTEEUS, 536 

neonatorum, 533 

Ichthyosis, 637 

Idiocy, 116 

Idiosyncrasies, 5 

Illusions, spectral, 109 

Imbecility, 116 

Impetigo, 630 

Incontinence of urine, 561 

Indications and contra-indications, 28 

Indigestion, 500 

Infantile jaundice, 533 

remittent fever, 332 

tetanus, 410 

Inflammation, acute, 266 

, causes which modify, 267 

, chronic, 263 

, related to nutrition, 63 

, terminations of, 64 

, theory of, 61 

, treatment of, 243, 268 

, varieties of, 64 

Inflammatory fever, 266 

Influenza, 455 

Intemperance, effect of, on health, 17 

Intermittent fever, 278 

Intestinal irritation, puerperal, 339 



- worms, 403 



Intestines, disorders of, treatment of, 234 

, distension by air, 518 

, haemorrhage from, 513 

, intussusception of, 515 

, large, inflammation of, 509 

, obstruction of, 514 

, perforation of, 515 

, small, inflammation of, 508 

, torpor of, 514 

, ulceration of, 298, 509, 510 

Intus-susceptio, 515 

Iritis, 591 

Irritant poisons, 651 

Irritation, constitutional, 99, 267 

, intestinal puerperal, 339 

, peritoneal puerperal, 339 

, spinal, 382 

Ischuria renalis, 555 



Isothermal lines in relation to disease, 12 
itch, 610 

Jaundice, 536 

of infants, 533 



Kidney, albumenoid degeneration of, 550 

, calculi in, 551 

, cystic diseases of, 549 

, fatty degeneration of, 549 

, granular disease of, 549 

, inflammation of, 543 

, tubercular and cancerous dis- 



ease of, 550 
King's Evil, 344 
Kyestein, 134 

Laryngismus stridulus, 453 
Laryngitis, 446 
Laryngoscope, use of, 449 
Larynx, diseases of, 446 
Laxatives, doses and formulae, 679 
Lead cholic, 517 

palsy, 399 

Lens, diseases of, 601 
Lepra tuberculosa, 637 

, vulgaris, 634 

Leprosy, 634 

-, Italian, 636 



Leucocythaemia, 262 

Leucorrhcea, 566 

Lichen, 633 

Life, theories of nature of, 33 

Lips, diagnosis by, 190 

Lithates of ammonia and soda, 1 29 

Lithiasis, 550 

Lithic acid, tests for, 128 

Liver, abscess of, 532 

, acute atrophy of, 533 

, albumenoid degeneration of, 540 

, circulation through, 75 

-, cirrhosis of, 530 

, congestion of, 527 

, fatty degeneration of, 539 

, function of 39 

, hydatid tumours of, 540 

, inflammation of, 529 

■ , malignant diseases of, 541 

, syphilitic diseases of, 539 

Locked jaw, 412 
Locomotor ataxy, 400 
Lousiness, 611 
Lumbago 357 
Lunacy, 117 
Lungs, bleeding from, 471 

, capacity of, 151 

, collapse of, 458 

, emphysema of, 464 

, examination of, 147 

, functions of, 48 

, gangrene of, 471 

, inflammation of, 468 

Lupus, 640 

Luxury, influence of, on health, 18 



INDEX. 



701 



Madness, 116, 415 
. • - — , canine, 413 

Malacosteon, 348 

Mal-assimilation, 42 

Malignant diseases, 8 7 

Malum Alepporum, 639 

Mania, 118, 415 

Mastication, 36 

Measles, 316 

Medicines, doses of. (See doses.) 

Melancholia, 118, 417 

Melama, 497, 513 

Melanosis, 87 

Melasma, 263 

Memory, 104 

Meningitis, 370 

, spinal, 381 

, tubercular, 372 

Menorrhagia, 565 

Menstruation, difficult, 565 

, excessive, 565 

, normal, 563 

, suspended, 563 

Mentagra, 616 

Mercurial stomatitis, 488 

tremors, 401 

Metallic tinkling, 160 

Metritis, 338, 568 

Microscopron Audouini, 615 

furfur, 614 

— mentagrophytes, 616 

Miliaria — Miliary fever, 627 

Milk fever, 339 

Milky urine, 132 

Mimosis inquieta, 264 

Mind, physiology and pathology of, 102 

, disorders of, 102 

Mineral waters, 215 

Moisture, its influence on health, 13 

Mollities ossium, 348 

Molluscum, 639 

Monomania, 118 

Mortality in males and females, 8 

at different ages, 9 

in town and country, 16 

Mouth, gangrene of, 489 

, inflammation of, 485 

Mucous rale, 159 

Mucus, properties of, in urine, 134 

Mumps, 494 
. Muscas volitantes, 604 
'. Muscular action, disordered, 205 

— rheumatism, 355 

sound, ] 60 

: Myelitis, 380 

Mycetoma, 619 

Myopia, 604 

Nakcotic poisons, 652 
Narcotico-acrid poisons, 653 
Narcotics, 243, 248 

, action of, on the nerves, 93, 243 

, doses and formula;, 664 



Narcotics and stimulants, formulae, 667 

Nephritis, 543 

Nerves, properties of, 90 

Nervous diseases, 361 

pain, 385, 387 

state, 264 

system, physiology, and patho- 
logy of, 88, 201 
Nettle-rash, 622 
Neuralgia, 385 

■ hysterical, 387 

of the face, 386 



Nitrogen, elimination of, 54 ; 

Nomenclature, medical, 21 

Nosology, 22 

Nursing, 250 

Nutrition and secretion, 69 

, disorders of, 81 



Oculae spectra, 111 
(Edema, 270 

(Esophagus, diseases of, 496 
Oidium albicans, 487, 488 
Oophoritis, 575 
Ophthalmia, catarrhal 585 

, gonorrhceal, 588 

, purulent, 586 

, rheumatic, 589 

•, strumous, 588 



Ophthalmoscope, use of, 593 

Osteo malacia, 348 

Otitis, 605, 606 

Ovarian tumours and dropsy, 576 

Ovary, inflammation of, 575 

Oxalate of lime, tests for, 129 

Ozone, 13 

PArx, 201, 385 
Painter's colic, 517 
Palpitation, 421 
Pancreas, diseases of, 542 
, function of, 40 



Palsy, 390 

, lead, 399 

, shaking, 402 

, wasting, 400 

Paracentesis, cranii, 373 
— , thoracis, 483 



Paralysis, 205, 390 

, agitans, 402 

of the nerves of sensation, 389 

face 396 

insane, 399 



, metallic, 401 

Paraplegia, 392, 441 

Parasites, animal, and entozoa, 610, 643 

, vegetable, 487, 507, 613-618 

Parotitis, 494 
Pathology, general, 33 

, of the circulation, 56 

fluids, 34 

nervous system, 88 



-, structural, 79 



702 



INDEX. 



Paupers, health of, 217 

Pectoriloquy, 160 

Pediculi, 611 

Pellagra, 636 

Pemphigus, 628 

Percussion of ahdomen, 143 

chest, 155 

Perforation of the stomach, 50-1 

Pericarditis, 426 

Pericardium, adherent, 429 

, dropsy of, 429 

, inflammation of, 426 

Peritonitis, 524 

, puerperal, 337 

— , tubercular, 525 

Pertussis, 465 

Pestis, 328 

Phlebitis, 443 

Phlegmasia dolens, 445 

Phlogosis, 266 

Phosphates, tests for, 130 

Phrenitis, 364 

Phthisis pulmonalis, 473 

Phthyriasis, 611 

Physiology and pathology, 33 

Piles, 518 

Pityriasis, 613, 636 

Plague, 328 

Plastic bronchitis, 459 

Plethora, 256 

Pleuritis— Pleurisy, 480 

Pleurodyne, 356 

Plica Polonica, 618 

Pneumonia, 463 

Pneumothorax, 484 

Podagra, 357 

Poisons, action of, on the nerves, 93 

■ , antidotes for, 655 

, irritant, 651 

, narcotic, 652 

, narcotico-acrid, 653 

Porrigo, decalvans, 615 

, lupinosa, 617 

, scutulata, 615 

Posture, influence of, on cerebral circu- 
lation. 79 

of the body, in disease, 206 

Predisposition, hereditary, 3 

Presbyopia, 604 

Prescriptions, 737 

Prisons, construction and arrangement 
of, 218 

Prisoners, health of, 217 

Prognosis, 25 

Protein, 39 

Prurigo, or Pruritis, 634 

Psoriasis, 630 

Ptosis, 398 

Puerile respiration, 157 

Puerperal fevers, 336 

Pulmonary consumption, 473 

Pulse, the, 171 

, character and varieties of, 178 



Pulse, diurnal variations of, 177 

. effect" of emotions on, 177 

— exercise on, 177 

— food on, 177 
sleep on, 177 



, in debility, 178 

, influence of posture, 176 



- temperament, 17 

- temperature, 177 



, in pulmonary consumption, 476 

, number of, at different ages, 172 

-, ratio of, to respiration, 184 

, venous, 72 

Pupil, diagnosis by, 204 
Purgatives, 235 

, doses and formulas, 682 

Purpura, 349 

Pus, properties of, in urine, 135 

Putrid sore throat, 321, 325 

Pyemia, 334, 497 

Pyrosis, 506 

Quinsy, 492 

Rachitis, 346 

Rales, 159 

Rashes, 307, 621 

Relapsing fever, 303 

Remedies, classification of, 229, 657 

Remittent fever, 313 

, infantile, 368 



Respiration, abnormal, 158 

, function of, 48 

■, normal, 157 



Respirations, at different ages, 183 

, diurnal variations of, 184 

, during sleep, 184 

, in different postures, 184 

-, in two sexes, 183 

, number of, 151, 183 

, proportion of, to pulse, 184 



Restoratives, 236 

Retina, diseases of, 596, 598 

Rheumatism, 352 

gonorrhceal, 578 



Rhonchus, varieties of, 159 

Rickets, 346 

Ringworm of the body, 616 

scalp, 615 

Roseola, 623 
Rubeola, 316 
Rupia, 629 

Sailors, preservation of health of, 220 

Saliva, in disease, 191 

Salivation, 488 

Salts, elimination of, 54 

Sarcina ventriculi, 537 

Scabies, 610 

Scall head, 617 

Scarlatina — Scarlet fever, 319 

Sciatica, 338 



INDEX. 



703 



Sclerotica, inflammation of, 539 
Scorbutus, 350 
Scrofula, 4, 344, 588 
Scurvy, 349 
Secretion, morbid, 71 

, physiology of, 70 

, remedies which promote, 246 

Sedatives, 242, 249, 664 

, and stimulants, formulae, 667 

, doses and formate, 664 

Semen in urine, 135 

Sensation, disorders of, 101, 201, 385, 339 

, paralysis of nerves of, 389 

Sense, organs of, 103 

Sex, its influence on disease, 5 

, on mortality, 6 

Shaking palsy, 402 

Sibilus, 159 

Sick, management of the, 250 

Sickness, influence of age on, 9 

Sight, sense of, diagnosis by, 2C3 

, long and short, 604 

Signs of disease, 23, 122 
Site and soil, 210 
Skin, diseases of, 608 

, classification of, 608 

, definitions of, 609 

, parasitical, 610 

, syphilitic, 579 



Stomach, acidity of, 506 ' 

, atony of, 505 

, cancer of, 504 

, congestion of, 497 

— , diseases of, 497 

, inflammation of, 499 

, haemorrhage from, 598 

, neuralgia of, 501 

, perforation of, 504 

, self-digestion of, 503 

-, ulcer of, 502 



, functions of, 50 

Sleep, 78 

Small-pox, 307 

Sneezing, 197 

Soldiers^ preservation of health of, 221 

Somnambulism, 114 

Sore-throat, inflammatory, 492 

Spasm of the heart, 424 

, tonic and clonic, 100, 205 

Spectral illusions, 109 
Spermatorrhoea, 583 
Sphygmograph, the, 182 
Spina bifida, 335 
Spinal apoplexy, 384 

concussion, 384 

cord, inflammation of, 380 

diagnosis of, 330 

effusion, 384 

irritation, 382 

meningitis, 381 

system, pathology of, 96 

Spirometer, the, 152 
Spitting of blood, 471 
Spleen, diseases of, 542 
Sputa, 198 
Squinting, 204 
St. Anthony's fire, 273 
St. Vitus's dance, 406 
Staphyloma posticum, 599 
States of systems, 256 
Stimulants, 238, 248, 657 

action of, on the nerves, 248 

and sedatives, formulas 667 

■ doses and formula?, 657 



| Stomachics, 232 
Stomatitis, 485 
Struma, 4, 344, 588 
Sugar in urine, tests for, 132 
Suppuration, 65 
Suppression of urine, 555 
Supra-renal cachexia, 263 
Sycosis menti. 616 
Sympathetic nerve, functions of, 93 
Sympathies, 95 
Symptomatology, 23 
Syncope, 424 

, anginosa, 423 

Syphilis, 578 

, infantile, 583 

■ — , local, 583 

System, states of, 256 

Tabes dorsalis, 4 00 

, mesenterica, 525 

Taenia, tape-worm, 648 

Taste, the, 191 

Teeth, diagnosis by, 190 

Temperament?, 2 

Temperature, its effect on health, 10 

Tetanus, 410 

neonatorum, 412 



Tetter, humid, 624 

, running, 633 

, dry, 635 

Therapeutics, general outline of, 229 

Thirst, 35, 192 

Thrombosis, 442 

Thrush, 486 

Tic doloreux, 386 

Tinea circinata, 616 

, favosa, 617 

, sycosa, 616 

Tongue, diagnosis by, 188 

. inflammation of, 491 

Tonics, 241, 668 

, doses and formulae, 668 

Tonsillitis, 492 

Torpor intestinorum, 514 

Torula cerevisia, 133, 507 

Touch, sense of, diagnosis by, 2C3 

Town life, influence of, on health, 15 

Tracheitis, 452 

Treatment of disease, 27 
I Trembles, the, 402 

Tremor mercurialis, 401 
| Trichina spiralis, 646 



704 



INDEX. 



Trichomonas vaginalis, 578 
Trichocephalus dispar, 646 
Trichophyton tonsuras, 616, 619 

, sporuloides, 618 

Trichuris, 646 
Trismus, 410 

, nascentium, 410 

Tubercle, 85, 474 
Tympanites, 518 
Typhous state, 291 
Typhus, fever, 288 
, icterodes, 284 

Ulceration, 66 

Urates of ammonia and soda, 129 

Urea and uric acid, composition of, 52 

Urea, tests for, 127 

Ureter, stone in, 549 

Uric acid, tests for, 128 

Urinary calculi, 559 

deposits, 127 

organs, diagnosis by, 200 

, diseases of, 543 

tubes, casts of, 136 

Urine, the, in health and disease, 51, 122 

, bloody, 552 

, chylous, 131, 559 

, difficulty in voiding, 562 

, immoderate flow of, 559 

, incontinence of, 561 

, morbid, 125 

, physical and chemical properties 

of, 122 

— , quantity of, 123 

, suppression of, 555 

, saccharine, 556 

, tables of solids contained in, 138 

, tests for, 126 et seq. 

Urticaria, 622 
Uterus, cancer of, 570 

, displacements of, 574 

, fibrous tumours of, 571 

, haemorrhage from, 565, 569 

, inflammation of, 338, 56S 

— , ulceration of, 569 



Vaccina, cow-pox, 313 

Vaccination, 313 

Varicella, 315 

Variola, 307 

Veins, inflammation of, 443 

Venous circulation, 71, 

, murmur, 259 

, pulse. 72 

Ventilation, 211, 251 
Vis medicatrix naturae, 26 
Vital principle, 33 
Vocal iremitus, 160 

sounds, 160 

Vomiting, 192 

of blood, 498 

sarcinae. 507 

, sympathetic, 507 

Warming, 211 
"Waste of the body, 35 
Water, elimination of, 53 

in the belly, 526 

chest, 482 

— head, 371. 

heart. 429 

spinal sheath, 380 

Water-bra>h, 506 

, impure, its effect on health, 1 7 

Waters, mineral, 215 
White leg, 445 
Whites, the, 566 
Whooping-cough, 465 
Windpipe, diseases of, 446 
Womb, cancer of, 570 

— , displacements of, 574 

, fibrous tumours of, 571 

, haemorrhage from, 565. 569 et seq, 

, inflammation of, 338, 568 

, ulceration of, 569 

Worms, intestinal, 643 

Yawning, 196 
Yaws, the, 284 
Yellow fever, 638. 



3477 



LONDON ." PRINTED BY WILLIAM CLOWES AND SONS, STAMrORD STREET 
AND CHARING CROSS. 



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